Annual Lifestyle Survey - Gateway Veterinary Clinic

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Are you or anyone in your household 65 years of age or older?

Yes
No

Please list all additional pets and their species here:

Do you use flea and tick control products?

Yes
No

Product(s) used:

Do you treat all pets in the household?

Yes
No

When was the last dose given/applied?

Do you give it year round?

Yes
No

Do you forget to administer?

Occasionally
Frequently
Never

Do you use heartworm prevention products?

Yes
No

Product(s) used:

Do you treat all pets in the household?

Yes
No

When was the last dose given/applied?

Do you give it year round?

Yes
No

Do you forget to administer?

Occasionally
Frequently
Never

Do you use dental products?

Yes
No

How often?

Daily
Weekly
Occasionally
Rarely

Please list any and all medications:

Please list any and all vitamins/supplements:

General health concerns (please check all that apply):

My pet has lost or gained weight recently
My pet's behavior or activity level has changed
My pet's behavior while urinating or defecating has changed
My pet's skin or hair coat has changed
My pet seems painful, weak, or exhibits tremors
My pet seems itchy

Which places does your pet go? (please check all that apply):

Where do they travel to?

Do you observe wild animals or other wildlife in your neighborhood? (please check all that apply):

Which of the following is true? (please check all that apply):

Other pets come into our home
Other pets come into our yard
My pet visits other homes with pets
We feed our pets outside
We feed wild animals/feral cats
We have seen parasites on our pet(s) previously

I feed my pet:

Dry
Canned
Both

What brand and flavor of diet do you feed your pet? How much and how often? How much exercise does your pet get daily?

Does your pet get treats? What kind and how many?

Additional concerns you would like to discuss:

Complete your annual lifestyle survey online.

Save time during your next visit by completing your annual lifestyle survey online before your next appointment. We look forward to seeing you soon!