What is your FIRST and LAST NAME? *

First

Last

What is your PET'S NAME? *

What is your phone number? *

Are there any additional people that you would like to add to your pet’s file? This would give them permission to make medical decisions for your pet. *

Yes
No

What is their name(s) and phone number and/or e-mail address?

If you’d like, please let us know how you heard about our clinic

Medical:

How is your pet doing overall?

Any current or recent coughing? *

Yes
No

When did the coughing start?

What time of day does the coughing occur?

Is the coughing worsening or improving?

Does the coughing worsen with activity?

Is the cough dry or productive?

Any current or recent sneezing? *

Yes
No

When did the sneezing start?

What time of day does the sneezing occur?

Is the sneezing worsening or improving?

Is there discharge from the nose? If so, what colour is the discharge?

Any current or recent vomiting? *

Yes
No

When did the vomiting start?

How often is the vomiting happening? How soon after eating?

Is the vomiting worsening or improving?

Is there blood in the vomit?

What is in the vomit? (ie: food, bile, foam, other)

Any history of dietary indiscretion?

Has there been a food change or different treats given?

Any current or recent diarrhea or soft stools? *

Yes
No

When did the diarrhea start?

How often is diarrhea occurring?

Is the diarrhea worsening or improving?

Is there blood or mucus in the diarrhea?

What is the fecal consistency?

Any history of dietary indiscretion?

Has there been a food change or different treats given?

Any changes in urination amount or frequency? *

Yes
No

Please describe:

Any changes in stool consistency or frequency? *

Yes
No

Please describe:

Any history of tremors, seizures, weakness, or collapse? *

Yes
No

Please describe:

Any new or changed lumps, or new skin lesions? *

Yes
No

Please describe:

Any current or recent scratching or hair loss? *

Yes
No

Please describe:

Any changes in vision or hearing? *

Yes
No

Please describe:

Any recent injuries or falls? *

Yes
No

Please describe:

Any changes in mobility (stiffness, soreness, changes in movement or jumping, or changes in activity level)? *

Yes
No

Please describe:

Please let us know any ongoing current medical concerns or conditions your pet has (if they have not been addressed by the previous questions)

Please let us know any past significant medical issues, previous surgeries, or hospitalizations

Has your pet had any reactions or side effects from previous medications or supplements? *

Yes
No

Describe their previous reaction

Has your pet ever had an allergic reaction or sensitivity to their vaccines? *

Yes
No

Describe their previous reaction

Has your pet had any poor reactions during previous anesthesia or surgery? *

Yes
No

Describe their previous reaction

Does your pet have any other allergies, or are there any serious allergies in the household to be aware of? *

Yes
No

Describe the allergy

Behaviour:

How is your pet’s energy level?

Have you noticed any changes in your pet's personality or behaviour recently? *

Yes
No

Please describe:

Any changes in sleeping habits? *

Yes
No

Please describe:

Any changes in the way your pet greets or interacts with other pets or people? * *

Yes
No

Please describe:

Any new fears, anxieties, stressors or phobias noticed? *

Yes
No

Please describe:

Are you concerned about any of your pet’s current or recent behaviours? *

Yes
No

Please describe:

If you have other pets in the household, describe your dog’s relationship with them

Has your dog shown biting, nipping, growling, or lunging at other pets or people? *

Yes
No

Please describe:

Are there any specific areas on your pet’s body that they are very nervous of having touched, or don't like having handled? *

Yes
No

Please describe:

How comfortable has your pet been at the vet previously?

Our goal is to minimize fear, anxiety, and stress during your pet’s visit to Whitehills. Please try to bring any special treats or toys to the appointment that can help soothe your pet. Please let us know any information that would help make your pet more comfortable during their exam with us.

Nutrition and Lifestyle:

Any changes in appetite? *

Yes
No

Please describe:

What type of food is fed? (include brand of food, dry or canned, homemade, etc) *

How much food is fed each day? *

Is your pet fed in meals or free choice? *

What treats and table food are fed, and how often? *

Can your pet have treats or canned food while they are here in the clinic? *

Has your pet had any reactions or sensitivities to specific foods or treats in the past? *

Yes
No

Describe their previous reaction

When did your pet last eat before their appointment? *

Do you want to discuss your dog’s nutrition at your appointment? *

Yes
No

Please describe:

Any changes in drinking? *

Yes
No

Please describe:

How much water is consumed daily? *

Describe your pet’s typical daily activity and exercise (ie length and frequency of walks, backyard time, etc). *

Are you concerned about your pet’s appetite, thirst, activity or weight? *

Yes
No

Please describe:

Any history of boarding or plans to board in the future?

Any recent or future plans to travel with your pet outside of London? *

Yes
No

What areas will your pet be traveling to?

Does your dog interact with any other dogs (i.e., at leash free parks, grooming, during walks, doggy play dates)? *

Are there any other pets at home that do not come to Whitehills? *

Yes
No

Please describe:

Please list all current medications (include medication name, strength, frequency of administration, and when the most recent dose was given). *

Please list all current supplements (include strength, frequency of administration, and when the most recent dose was given). *

Are any over the counter products (spot-on, shampoos, foams, sprays) used? *

Yes
No

What is the name of the product?

When was it last applied?

Do you have any questions regarding pet insurance? *

Yes
No

Please describe:

Preventative Care

Please note that the preventative care options listed below have an additional charge on top of the annual examination fee. Any additional diagnostics or treatment pursued at the appointment (including nail trims) will also be associated with a fee. Please let us know at your appointment if you would like to review costs prior to proceeding with additional services. *

I understand

We recommend that core vaccinations (Rabies, and Distemper/Parvovirus vaccines) are kept up-to-date to ensure the protection of your pet against serious and life-threatening diseases. WOULD YOU LIKE TO PROCEED WITH CORE VACCINES (IF DUE)? *

Yes
No
I would like more information

The kennel cough vaccine minimizes signs of clinical disease from the most common respiratory infections passed from dog to dog. It is typically recommended for dogs with close contact to other dogs (ie at boarding, grooming, dog parks). It is also typically recommended for puppies, seniors and brachycephalic breeds due to their higher risk of illness from kennel cough. WOULD YOU LIKE TO PROCEED WITH THE KENNEL COUGH VACCINE? *

Yes
No
I would like more information

Leptospirosis is a serious bacterial disease that is transmitted by common wildlife and is present within the city of London. Infection with this bacteria, through contaminated soil or water sources, can cause severe kidney and liver disease in dogs, and can also be transmitted to people. WOULD YOU LIKE TO PROCEED WITH THE LEPTOSPIROSIS VACCINE? *

Yes
No
I would like more information

Lyme disease is caused by a bite from an infected deer tick. The Lyme vaccine is recommended for dogs traveling to high risk areas for ticks to provide additional protection against this disease. Current high risk areas for Lyme in Ontario are: the majority of the coastline of Lake Ontario and Lake Erie, Grand Bend, Hamilton/Wentworth, and some areas in the Toronto-Montreal corridor. WOULD YOU LIKE TO PROCEED WITH THE LYME VACCINE? *

Yes
No
I would like more information

Parasite Prevention:

Parasites in our pets are grouped into 3 main categories:

Internal parasites: These include intestinal worms and other parasites, which can be picked up in the outside environment.
External parasites: Include fleas and ticks, which can pass additional infectious diseases through bites.
Heartworm: Passed through a bite of an infected mosquito and can cause serious irreversible heart and lung disease.

Due to the changing climate and warmer winters, parasite prevention is now recommended year-round. The most complete parasite prevention covers fleas, ticks, heartworm and intestinal parasites (including tapeworm).

If your pet has had parasite prevention from a previous clinic, would you like the same prevention prepared? *

Yes
No

How many doses of prevention would you like? *

Would you like to discuss a new parasite prevention plan for your pet? *

Yes
No, I do not want any prevention today

Do you prefer topical or oral medication? *

Which parasites do you want coverage for? *

Fleas
Ticks
Intestinal parasites
heartworm

Any difficulty administering prevention previously? *

Any adverse reactions to previous preventions? *

A 4Dx blood test checks for heartworm and 3 tick-borne diseases (including Lyme disease). This test is recommended annually to check for exposure to these diseases. To abide with manufacturer label requirements, an up-to-date heartworm test is required in order to dispense heartworm medication. Do you consent to a 4dx blood test (if due)? *

Yes
No

Wellness bloodwork can be pursued at any age and is highly recommended for senior pets (over 7 years old). This bloodwork assesses blood cells and main organ parameters (i.e. liver, kidneys, protein levels, sugar levels). It can also include additional information (such as thyroid levels and electrolytes). Wellness bloodwork can be a helpful screening tool for early disease detection (catching illness before any signs of disease are seen clinically). ARE YOU INTERESTED IN PURSUING WELLNESS BLOODWORK FOR YOUR PET? *

Yes
No
I would like more information

Microchipping is implanting a small chip (the size of a grain of rice) between the shoulder blades - this identifies your pet to connect them back to you if they become lost. Microchipping is strongly recommended if you will be traveling internationally with your pet (ideally prior to Rabies vaccination). This can be done at any appointment. Would you like to have a microchip placed today? *

Yes
No, My pet already has a microchip
No, I am not interested
I would like more information

A fecal sample can be tested annually in order to check for the most common intestinal worms and parasites. If you would like us to run this, please bring a fresh stool sample (<24h old) with you to your appointment. *

I understand

Please let us know any further information on what’s important to you for your pet’s health, including observations, questions, or concerns to address at your appointment

Thank you for taking the time to fill out this questionnaire. We look forward to meeting you at your appointment!
- The Whitehills Team

New Patient Canine Annual Form