Canine Medical History Form
ADVERTISEMENT
1CANINE MEDICAL HISTORY FORM
Owner:
Pet Name:
Color:
Age / Birthdate:
Breed:
Sex: □
Date:
M □ Neutered
□
F □ Spayed
ABOUT YOUR DOG
1. Your dog was obtained from: D Breeder □ Pet store □ Friend □ Stray D Humane Soc.
□ Other
2. Your dog is: □ Indoor
□ Outdoor
□ Both
Number of dogs in household:
3. Brand of pet food:
□ Canned
□ Dry
4. How is your dog's appetite: D Normal
□ Other:
How is your dog's attitude: □ Happy-Active-Normal
□ Depressed-Lethargic
□ Other:
Is your dog drinking: □ Normally D More
□ Less than usual.
5. Do you notice any of the following: □ Limping
□ Eye Discharge
□ Nasal discharge
□ Sneezing
□ Coughing
□ Shaking head
□ Scooting
□ Scratching
□ Vomiting
□ Diarrhea
□ Lumps
□ Bad breath often
□ Weight loss
□ Lethargy / weakness
□ Seizures
□ Hair loss
□ Pain or straining when urinating / defecating:
YOUR DOG'S MEDICAL HISTORY
1. Previous veterinary hospital:_
May we request your records from their office?
□ Yes
D No
□ First visit to a veterinarian
2. Has your dog had the following in the last 12 months:
Physical examination: □ Yes date:
D No
□ Unsure
Dental examination and cleaning: □ Yes date:
D No
□ Unsure
Heartworm test: □ Yes date:
D No
□ Unsure
Fecal sample test: □ Yes date:
D No
□ Unsure
Blood testing for kidney & liver function: □ Yes date:
D No
□ Unsure
3. Has your dog been vaccinated for the following in the last 12 months:
Rabies:
□ Yes date:
D No
D Unsure
Canine Distemper: □ Yes date:
D No
D Unsure
Lyme Disease:
□ Yes date:
D No
D Unsure
Canine Cough:
□ Yes date:
D No
D Unsure
4. Has your dog been dewormed in the last 12 months: D Yes date:
D No
□ Unsure
5. Flea & tick preventative(s):
□ Collar
□ None
6. Heartworm preventative:
□ None
7. Are you familiar with geriatric care for dogs over 7 years of age: □ Yes □ No
8. Current medications and allergies:
COMMENTS:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical