Dog Risk Assessment Form Client InformationNameEmail address Client address: PhoneRisk AssessmentDog's NameDog's AgeNumber of dogs in householdDoes your dog go outdoors?YesNoIf so, is the dog supervised while outdoors?YesNoWhat 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?YesNoIf so, please explain.Does your dog come into contact with other cats' environments, including stray animals?YesNoIs there wildlife in your area, including mice, squirrels, birds, possums, racoons, skunks or deer?YesNoHave you found ticks on your pets or are there ticks in your area?YesNoDo you travel with your dog to areas where ticks or mosquitoes may be present?YesNoIf you do, do you travel through the Southeastern U.S.?YesNoDoes your dog have an opportunity to drink from standing water outdoors (ponds, puddles, etc.)?YesNoDoes your dog sleep with you or your children?YesNoDo you ever take your dog to a groomer, boarding facility, pet store, or training classes?YesNoDo you ever take your dog to shows?YesNoDo you ever take your dog hunting?YesNoIf yes, do you travel out of state?YesNoIs your pet spayed or neutered?YesNoIs your dog on monthly heart-worm preventative?YesNoHve you ever missed a heart-worm dose by more than two weeks?YesNoIs anyone in your household immuno-compromised?YesNo
