Canine Clinical Medical History

Please complete this form thoroughly. The information you provide will help the doctor understand your dog's history and help provide the best possible treatment.
Caregiver's Name

First NameLast Name
Dog's Name
Dog's Date of Birth

MonthDayYear
Date
Dog's Weight
Photo of your dog

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Photo of your dog's tongue

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Video (link) of your dog walking toward camera, away from camera and from the side. Upload to YouTube and provide a link.
Tell us a little about your dog and the current situation concerning you.
Please list ALL current medications and supplements your dog is taking, including dose and frequency. Include heartworm and flea/tick preventive.
Does your dog prefer taking medications in liquid, powder, or pill form?
Please list ALL food and treats your dog currently eats. Include foods given by others (friends, neighbors, etc.) or given infrequently.
Describe your dog’s appetite and eating habits.
What type of water does your dog drink?
Describe your dog’s thirst.
What is the usual color of your dog's urine? Does your dog mark or go all at once? Does your dog have excessive frequency of urinations or amount of urine? Straining, blood or mucus?
How often does your dog have a bowel movement? How often are they abnormal (soft or hard)? Color, odor and consistency of abnormal stools? Usual color, odor and consistency. Any straining blood or mucus?
Does your dog excessively lick genital or anal area? If so, please describe.
If eye discharge is present, describe side(s) affected, amount, frequency, thickness and color. Is it irritating to the patient/tissues.?
If ear discharge is present, describe side(s) affected, amount, frequency, thickness and color. Is it irritating to the patient/tissues.?
If skin eruptions are present, describe side(s) of the body and areas affected, amount, frequency, size and color. How irritating are they to the patient 0-10/10?
List all treatments your dog is currently receiving. What has been the response to each treatment?
Describe all exercise/activities your dog engages in, including frequency and duration.
Describe any significant emotional or behavioral patterns.
Does your dog get hot or cold easily?
Please indicate the severity of each issue below by clicking or sliding the bar right to indicate mild, moderate, or severe.
Sympathetic
Parasympathetic
Carbohydrate Metabolism, Sugar Handling
Circulation
Hepatic, Gall Blader
Digestive
Thyroid Gland
Pituitary Gland
Adrenal Glands, Hyperactive
Adrenal Glands, Hypoactive
Musculoskeletal (Calcium / Magnesium Metabolism)
Renal
Immune
Pain
For any issue marked on the form please answer the following: Is there any time of day or seasonal change? Is there anything that makes it better or worse?
Please list below the five main physical and or health complaints for this dog in order of importance.
This is a lengthy form and technical glitches can happen.

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