Canine History Form
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Complete Canine History Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1Canine History Form
Pet Owner's Name:
Pet's Name:
Lifestyle
How long haveyou owned your pet?
Where did you get your pet?
Are there any other pets in your household?
Has your pet ever lived outside of Las Vegas? Please list where and when:
Do you travel with your pet outside of Las Vegas? Please list where and when:
Dog Aggressive
Is your pet:
People Aggressive
Food Aggressive
Cage Aggressive
Medical History
Please list the name of your previous vet:
When did your pet last receive:
Lyme:
Rabies:
Distemper:
Parvo:
Bordetella:
Fecal:
Heartworm Test:
Heartworm Prevention:
No What is the microchip number?
Is your pet micro-chipped?
Yes
Please list any previous surgeries your pet has had:
Is your pet on any medication or supplements? Please list medication, dosage, and how often it is given:
Does your pet have a history of (please select all that apply):
Coughing
Vomiting
Diarrhea
Sneezing
Weakness
Ear Infections
Allergies
Arthritis
Hair Loss
Kidney Disease
Thyroid Disease
Seizures
Heart Disease
Liver Disease
Foreign Body
Bladder Infections/stones
Diet
Which brand of food do you feed your pet?
Does your pet eat dry food, wet food, or both?
How much and how often do you feed your pet?
Do you give your pet any treats?
Yes
No
What kind?
Do you give your pet any human food?
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Parent category: Medical