SMR Owner History Survey

Company

This field is for validation purposes and should be left unchanged.

Dog's Name*

Owner's Name (first/last)*

Is your dog currently on the following preventative care?*

Rabies vaccine

Distemper vaccine

Lyme vaccine

4DX (annual heartworm/tick test)

Flea/tick prevention

Heartworm prevention

No preventative care

What kind of flea/tick prevention do you use?*

Isoxazolines (Simparica, Bravecto, Credelio, Nexgard)

Topicals (K9 Advantix, Frontline, Vectra)

Seresto collar

Other type of collar

Essential oil sprays

None

Other

If you selected other, please include here:

What is your dog's diet? Please list brand, type (kibble/canned/fresh), amount, frequency, and types/amounts of treats given.*

Please list all medications, including the drug name, dose, and frequency of administration, that your pet takes:*

Please list all supplements, including name, dose, and frequency of administration, that your pet takes:*

Which of the following sporting/working activities does your dog participate in?*

If you selected other, please include here:

Please describe your dog's involvement in these activities (number of hours/days practicing and competing per week, etc.). If your dog is retired, please list the age at retirement and the length of his/her sporting/working career.*

Does your dog go for regular walks? On or off leash? Approximately how long and how often?*

Does your dog participate in regular off leash activity? Please describe.*

If you have rested your dog, please describe the duration and degree of activity restriction (strict crate rest, discontinuing sport/walks, keeping off furniture, etc.).*

What is your primary concern for today's visit?

What are your goals for your sports medicine and rehabilitation appointment?*