Canine Lifestyle Intake Form Name* First Last Pet Name*Is there anything you would like to do with your dog, but can’t?Where does your dog spend time?* In the house In the yard In a body of water In the woods/nature With other dogs Vacations/roadtrips? Doggy Daycare Dog Parks Does your furry pal scratch, chew, lick, or rub any part of his or her body?*YesNoIf yes, which parts of the body are affected? Belly/Stomach Groin Legs Nose Tail Back Ears Face Chest Side Feet/Paws Did your dog vomit on the way to the clinic today?*YesNoHas your dog shown any of the following signs during car rides? Vomiting Excessive panting Excessive lip licking Inactivity Shaking Restlessness Drooling Is your dog lagging behind, limping or reluctant to enage in normal activities? Limping after exercise Difficulty jumping Lagging behind on walks Feeling stiff Slow to rise Difficulty with stairs Does your dog react, become anxious or fearful to loud noises?*YesNo(Such as fireworks, thunder, construction, celebrations, etc.)When your dog reacts to loud noises, what signs do they show? Pacing or restlessness Lip licking Trembling or shaking Panting Vocalizing (whining or barking at the sounds) Cowering Hiding Brow furrowed or ears back Freezing or immobility Owner seeking behavior or abnormal clinginess Any other signs?EmailThis field is for validation purposes and should be left unchanged.