Risk Assessment Form

Animal Hospital of Warwick

2370 York Road, Commonwydds A-1
Jamison, PA 18929

(215)343-5300

www.animalhospitalofwarwick.com

Risk Assessment Form

This form must be completed annually for dogs and cats prior to their wellness examinations. The veterinarian will decide the best vaccine protocol for your pet based on your responses to the questions. Please complete this form and bring to your pet's annual examination.

Risk Assessment Form

Client Name: *(required)*

First Name (required)	Last Name (required)

Date of Appointment: (required) :

Disease Risk Assessment Form for (Pet's Name): (required)

When your pet goes outdoors, is it ever unsupervised? (Outdoor time counts as unsupervised any time a human isn’t present, even if the pet is fenced in or leashed.) (required)

Yes
No

Do you have a fenced yard or invisible fence? (required)

Yes
No

Does your pet come into contact with other pets or their environments? (required)

Yes
No

Is there wildlife in your area (mice, squirrels, birds, opossums, raccoons, skunks, etc)? (required)

Yes
No

Have you seen ticks on yourself or your pet, or in areas you frequent with your pet? (required)

Yes
No

Does your pet have any opportunity to drink from standing water (ponds, puddles, etc) outdoors? (required)

Yes
No

Does your pet sleep with you or your children? (required)

Yes
No

Do you ever take your pet to a groomer or boarding facility? (required)

Yes
No

Do you ever take your pet to cat or dog shows? (required)

Yes
No

If you own a dog, do you ever take it hunting? (required)

Yes
No

Does your cat hunt? (required)

Yes
No

Do you travel with your pet? (required)

Yes
No

If your pet is on a monthly heartworm preventative, have you ever missed a dose by more than two weeks? (required)

Yes
No

If your pet is on a monthly tick control product, have you ever been late to apply it, missed a dose, or skipped a month? (required)

Yes
No

What tick control product do you use? (required)

Today's Date: (required) :

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