Client InformationName Email address Client address: Phone Risk AssessmentDog's Name Dog's Age Number of dogs in household Does your dog go outdoors? Yes No If so, is the dog supervised while outdoors? Yes No What percentage of time does your dog spend indoors? What percentageof time does your dog spend outdoors? Has this dog had any reaction to a vaccination in the past? Yes No If so, please explain. Does your dog come into contact with other cats' environments, including stray animals? Yes No Is there wildlife in your area, including mice, squirrels, birds, possums, racoons, skunks or deer? Yes No Have you found ticks on your pets or are there ticks in your area? Yes No Do you travel with your dog to areas where ticks or mosquitoes may be present? Yes No If you do, do you travel through the Southeastern U.S.? Yes No Does your dog have an opportunity to drink from standing water outdoors (ponds, puddles, etc.)? Yes No Does your dog sleep with you or your children? Yes No Do you ever take your dog to a groomer, boarding facility, pet store, or training classes? Yes No Do you ever take your dog to shows? Yes No Do you ever take your dog hunting? Yes No If yes, do you travel out of state? Yes No Is your pet spayed or neutered? Yes No Is your dog on monthly heart-worm preventative? Yes No Hve you ever missed a heart-worm dose by more than two weeks? Yes No Is anyone in your household immuno-compromised? Yes No
