980-938-8136
wbah@westbah.com
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Dog Wellness Questionnaire

Please complete the online form below prior to your visit at
West Ballantyne Animal Hospital.

Get Started

Dog Wellness Questionnaire

Please complete the form below as thoroughly as possible.

- Step 1 of 3

Name *

First

Last

Phone *

Email *

Pet's Name *

Are there any specific concerns you would like to address with the veterinarian? (Please be specific with details about severity or duration) *

How would you describe your pet's lifestyle? *

Strictly indoors
Mostly indoors - only outside for bathroom
Mostly indoors – a few hours outside daily
Strictly outdoors

How often does your pet visit dog parks, grooming facilities, boarding facilities or breweries? *

Weekly
Monthly
Quartely
Rarely
Never

Is your pet's home adjacent to wooded areas and wildlife? *

Yes
No

Do you bring your pet on walks/adventures on greenways, trails, hiking, camping? *

Often
Rarely
Never

What preventatives is your pet on? Please list specific product names. How many doses has your pet had in the past 12 months? *

What type of food do you feed your pet? Please be specific with brand, type, flavor of food *

Is this food grain free? *

Yes
No
Uncertain

Please list all medications and/or supplements that your pet gets regularly or sporadically *

Over the past 12 months, have you noticed any changes in the following

Appetite *

Yes
No

Coughing / Sneezing / Breathing *

Yes
No

Drinking Habits / Water Intake *

Yes
No

Urinary Habits *

Yes
No

Defecating Habits *

Yes
No

Frequency of Vomiting *

Yes
No

Grooming Habits or Coat Appearance *

Yes
No

Changes in Energy Level / Slowing Down *

Yes
No

Personality or Sociability Changes *

Yes
No

Mobility Changes *

Yes
No

New / Concerning Skin Growths *

Yes
No

Have you or anyone in your household experienced flu-like symptoms recently? *

Yes
No

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Location

11926 Providence Rd W Suite E0
Charlotte, NC 28277



Hours

Mon - Fri: 7:30 AM - 6:00 PM
Sat: CLOSED
Sun: CLOSED

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Contact

Phone: 980-938-8136
Email: wbah@westbah.com

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For Emergencies Contact

Carolina Veterinary Specialists

Charlotte: 704-504-9608
2225 Township Rd
Charlotte, NC 28273

Matthews: 704-815-3939
4099 Campus Ridge Rd
Matthews, NC 28104

Drop us a line!

Have a question? Use the form below, and we'll get back to you as quickly as possible. If you need immediate assistance, please call us directly at 980-938-8136.

Name *

First

Last

Email *

Phone

How can we help you? *

Phone

Download our app and connect with us on PetDesk!

Keeping up with your pet’s health from your mobile device has never been easier! With our new app, you’ll have all of your pet’s health information in the palm of your hand. Consider it your pet’s personal organizer app. Best of all, it’s free! Plus, you’ll be able to communicate with us much easier:

Request Appointments 24/7
Access Your Pet’s Medical Records
Organize all of Your Pet’s Important Information
Receive Automatic Reminders
Save Notes, Pics, and Much More
Two-Way Texting With Our Team

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