Health Form

Owner's first & last name
Pet's name
Has your pet experienced any of the following health issues?
- Coughing
- Sneezing
- Vomiting
- Diarrhea
- None
Please check all that apply.
Has your pet been eating and drinking as usual?
- Yes
- No
If you answered "no" to the question above, please describe changes observed
What brand of food does your pet typically eat?
How much food does your pet get per meal/per day?
How often does your pet get treats? What brand does (s)he enjoy?
Does your pet get any "people food" or table scraps?
- Yes
- No
How often is your pet on Flea/Tick prevention?
- Year Round
- Seasonally
- My pet is not on flea/tick prevention
When was your pet last treated with flea/tick prevention?
What brand/type of flea/tick prevention do you use?
How often does your pet get heartworm preventative?
- Year Round
- Seasonally
- My pet is not on heartworm prevention
When was your pet last treated with heartworm preventative?
What brand of heartworm prevention do you use?
Please check all places that your pet frequents
- Training Class
- Grooming Salon
- Dog Park
- Dog Daycare
- Boarding Kennel
Does your pet engage in any of the following activities?
- Hiking
- Camping
- Hunting
Which of the following areas does your pet have access to?
- Wooded areas/areas where wildlife is present
- Natural water sources (puddles, creeks, lakes)
Have you noticed any new lumps or bumps on your pet?
- Yes
- No
If you answered "yes" to the question above, please indicate where the lumps/bumps are located
Please describe any behavior or anxiety issues you would like to discuss:
Please list all medications and supplements (including dose and frequency)
Please list any medications or preventatives for which you would like a refill:
If your pet is an intact (un-spayed) female, when was her last heat cycle?
Are there any other concerns you would like the veterinarian to address?
Are there additional services you would like to request?
- Nail trim
- Anal gland expression
- Other
Please check all that apply

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12638 Main Rd, Rt 5
Akron, New York, 14001

Ph: 716-542-2208

akronanimalhospital@gmail.com

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Hours of Operation

Monday through Friday
8:00am – 6:00pm

Saturday
8:00am – 12:00pm