Health Survey Dog’s Name * First Name Last Name Human’s Name * First Name Last Name When is your BDay? MM DD YYYY Do you have a Gender Preference? Female Male They/Them Something I don’t know about because I’m a millennial. Dude Neutral Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Approximately, how old is your dog? * Is Your Dog: Female Male Is your Dog Intact Spayed or Neutered What is your Primary Veterinary Office? * Any Previous or Current Injuries, Illness, or Allergies? * Any Current Medications? * What brings you to the lab? * Pain Relief Preventative Care Longevity Fitness Senior Dog Care Puppy Health Plan How did you hear about us? * PDX Pipeline Google Search Referral Social Media It’s a Long Story… Met Dennis out and about. Anything else to share? If your dog has had any physical or emotional changes in the past 6 months, please share. Examples: Weight Gain or Loss, Limping, Reactivity, Aggression. Thank you!