Risk Assessment Form

If you are a new client, we would appreciate you filling out this form prior to your visit. For existing clients, we request that you fill this form out on an annual basis so that we may remain aware of your pet's environment and home care. We have hard copies for your convenience at our office.

Risk Assessment Form

* Indicates required field

Your Name *

First

Last

Today's Date *

Email *

Phone Number *

Pet's Name *

First

Last

How many dogs live in your home? *

How many cats live in your home? *

Please list any other pets that live in your home: *

TRAVEL & OUTDOORS

How much time does your pet spend outside on a daily basis? *

Are they always supervised while outside? *

Yes No N/A

Does your pet go to places popular for pets? (For example, parks, dayboarding facilities, obedience training, etc? If so, please list: *

Do your take your pet hiking, fishing, or camping? *

Do you ever travel with your pet? If so, please list where you go: *

Home Environment and Care

Do you observe wild animals around your neighborhood? For example, feral cats, deer, coyotes, foxes, squirrels, raccoons, etc? If so please list: *

Does your pet visit homes with other pets? *

Yes No N/A

Do other pets visit your home? *

Yes No N/A

Does anyone living in or visiting your home have a compromised immune system? *

Yes No Not sure

Which of you pets do you treat for fleas, ticks, parasites, or heartworms? *

Dog(s) Cat(s) None

Please list all products, medications, or supplements you give your pet: *

Is your pet allergic to anything (including food or medications)? If so, please list: *

What kind of exercise does your pet get? *

What kind of food do you feed your pet? How much per day? *

Is your pet a picky eater? *

Yes No Not sure

Do you change your pet's food often? *

Yes No Sort of

What kind of treats do you feed your pet? Please list all types and how often *

Unusual Behavior

Does your pet scratch or seem itchy? *

Yes No Not sure

Does your pet chew or lick their feet a lot? *

Yes No Not sure

Does your pet drag their rear end a lot? *

Yes No Not sure

Have you noticed any changes in your pet's weight lately? *

Yes No Not sure

Have you noticed any change in your pet's skin or coat? *

Yes No Not sure

Does your pet seem to suffer from any joint pain? *

Yes No Not sure

Have you noticed any changes in urinating or defecating behavior? *

Yes No Not sure

Have you noticed any vomiting or diarrhea recently? *

Yes No Not sure

Have you noticed any changes in activity level? *

Yes No Not sure

Have you noticed any changes in eating or drinking intake? *

Yes No Not sure

Does your pet have a history of seizures? *

Yes No Not sure

Please list any and all concerns regarding your pet (including problems or symptoms) that you would like for your veterinarian to address: *

If so, please describe any changes *

I agree to receiving marketing and promotional materials

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OFFICE HOURS

Monday 7:30 am - 6:00 pm
Tuesday 7:30 am - 6:00 pm
Wednesday 7:30 am - 6:00 pm
Thursday 7:30 am - 6:00 pm
Friday 7:30 am - 6:00 pm
Saturday 8:00 am - 12:00 pm
Sunday 5:00 pm - 6:00 pm*
*Sundays~ boarding services only

CONTACT INFORMATION

Adams Farm Animal Hospital, P.A.
5502 Adams Farm Lane
Greensboro, NC 27407

Phone: 336-854-5980
Text: 336-383-1487
Fax: 336-852-4861
Email: [email protected]

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