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22320 Salamo Rd,
West Linn, OR 97068

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Services
Holistic Care
About
Resources
Contact
Emergency

CANINE ANNUAL EXAM HISTORY

Canine Annual Exam History

"*" indicates required fields

Pet Name:*

Client Name*

First Last

Name & Phone Number for Decisions*

Email*

Do you have time constraints?*

Does your pet have insurance?*

Yes

No

If "Yes" above please let us know which Insurance Company

For today's visit the following symptoms are present:

No symptoms present

Coughing

Sneezing

Vomiting

Diarrhea

Lethargy

Lameness

Itching

Lumps/Bumps

Other Symptoms/Concerns (list):

Other Symptoms/Concerns (list):*

Diet: (what brand of food and amount fed per day. i.e. 2 cups twice daily, 1/4 can three times daily)*

Any change in food/treats?*

YES

NO

Current medications/supplements and dose given:*

Monthly heartworm / deworming / flea preventive:*

None

Trifexis

Interceptor Plus

Heartgard

Nexgard

Bravecto

Revolution

Cheristin

Vectra

Frontline

Advantage

Simparica Trio

Appetite:*

Normal

Decreased

Increased

Water Intake*

Normal

Decreased

Increased

Activity Level*

Normal

Abnormal

Food Allergies?*

Other Allergies?*

Any seizures?*

Percentage of time spent indoors:*

HISTORY

How is your pet doing at home?*

Have you noticed any changes to their normal behavior?*

YES

NO

What concerns that you would like to address today?*

Do you need any medication refills?*

YES

NO

Other

Vaccine Lifestyle Information and Consent

Do you take your pet hunting/hiking/camping/swimming, or playing in/near rivers ?*

YES

NO

Does your pet have exposure to standing water puddles, parks, water features, etc?*

YES

NO

Is there a possibility of sniffing the ground where rats or wildlife have been?*

YES

NO

Does your dog go to day-care/boarding/grooming/dog parks?*

YES

NO

Does your dog have exposure to ticks (wooded areas)?*

YES

NO

Vaccines Accepted/Declined for Upcoming Year

DHPP (distemper/parvo vaccine):*

ACCEPT

DECLINE

Leptospira (transmitted in urine of animals - contagious to people):*

ACCEPT

DECLINE

DHLPP (if receiving both the DHPP and Lepto):*

ACCEPT

DECLINE

Rabies:*

ACCEPT

DECLINE

Bordetella (for kennel cough):*

ACCEPT

DECLINE

Influenza (canine flu vaccine - recommended with exposure to other dogs such as dog parks, grooming, day care, and boarding:*

ACCEPT

DECLINE

Vaccine Titer (can be done in place of DHPP):*

ACCEPT

DECLINE

Entering Your Full Name Here Will Serve As Your Digital Signature:*

Date*

MM slash DD slash YYYY

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Email

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Cascade Summit Animal Hospital

22320 Salamo Rd
West Linn, OR 97068

Cascade Summit Animal Hospital is a full service animal hospital, providing medical, dental, diagnostic, surgical and holistic services

https://cascadesummitvets.com/

Hospital Hours

Monday	8:00 am - 6:00pm
Tuesday	8:00 am - 6:00pm
Wednesday	8:00 am - 6:00pm
Thursday	8:00 am - 6:00pm
Friday	8:00 am - 6:00pm
Weekend	CLOSED

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