Pet Health Questionnaire

PART 1: About you

(* = required field)

Your Name

Your Email

Your Address

Telephone

PART 2: About your pet

1

Do you have a

Dog or a Cat *

2

Type or breed

3

Your Pet's Name

4

Your Pet's Age

Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16+

5

Is your pet

Male or Female ? *

6

Has it been

Spayed or Neutured ?

7

Weight of Animal

(in lbs)

8

Has your pet been diagnosed by a Vet?

Yes No *

9

If so what was the diagnosis?

Questions 10 to 16 relate to possible symptoms, please tick all that apply.

10

Does your pet eat grass?

11

Does your pet chew its feet?

12

Runny eyes / build up of matter at the eyes?

13

Does your pet have dry skin like dandruff?

14

Is your pet constantly scratching?

15

Can you feel the animal's ribs?

16

Ear Problems / Wax Build Up / Ear Infection?

17

Pet shedding

Select Once a year Twice a year More than twice a year All the time

18

Pet feeding?

Select Once a day Twice a day Free fed

19

Pet eating?

Select All at Once Leaves some for Later

20

What foods does your pet eat?

Tell us as much as you can about what your pet eats now.

Any other comments