Canine Health History Form

Canine Health History Form

Fairfax Campus
Primary Owner Name:*

First NameLast Name
Email:*
example@example.com
Patient Name:*
Patient Date of Birth:*

MonthDayYear
Date
Patient Sex:*

Male, IntactMale, CastratedFemale, IntactFemale, Spayed
Patient Breed:*
Patient Weight (in pounds/lbs):*
Patient Weight (in kilograms/kg):*
This field has been automatically calculated based on the Patient's weight in pounds/lbs.
At which location are you requesting an appointment?*

Fairfax, VA CampusRichmond, VA Campus
Primary (general practice) veterinary clinic:*
Primary veterinary clinic phone number:*
Please enter a valid phone number.
Primary veterinary clinic email address:*
ABWC will request your pet's medical history using this address.
Veterinarian name (if you see a particular doctor):

First NameLast Name
Date of last veterinary visit:*

MonthDayYear
Is your dog’s rabies vaccine up-to-date?*

YesNo
Rabies vaccine date administered:*
Rabies vaccine location administered (name of hospital or clinic):*
Duration of rabies vaccine administered:*

1 year3 years
Rabies vaccine due date:*
Due date is reflected on your pet's current rabies certificate.
Please provide details of why your dog’s rabies vaccination is not current:*
Indicate any specialty veterinarian services your dog has received (other than your primary care provider):*

BehaviorCardiologyInternal MedicineNeurologyDermatologyOphthalmologyOrthopaedicOncologyRehabilitationNoneOther
Name / phone number / address of specialty practice:
Name / phone number / address of specialty practice:
Name / phone number / address of specialty practice:

Please list ALL of the medications your dog currently takes:*

Rows	Name of medication	Route of administration (oral/topical)	Dose (mg or mL)	Frequency administered	Dog's response to the medication
Heartworm prevention
Flea/tick prevention
Other
Other
Other
Other
Other
Other
Other

Has your dog taken any OTC behavior products or prescription medications in the past that have been discontinued due to an adverse response or lack of responsiveness?*

YesNo

Any changes in eating or drinking within the last year?*

YesNo
Please explain the changes:*
Has your dog presented with any of the following in the past year? Please check all that apply.

CoughingSneezingVomitingDiarrheaLumpsBumpsPainLimpingNone of the aboveOther
If you marked any of the above, please explain:*
Has your dog ever had a seizure?*

YesNo
Has your dog had puppies?*

YesNo
How would you describe your dog's energy level?*

Very Low - Doesn't like walks or playtime. Sleeps a lot. May be affectionate or not.Low - Has episodes of play and goes on short walks, but sleeps a lot otherwise.Moderate - Enjoys walks, distinct sleep-wake times throughout the day, will play if engaged.Moderate-High - Requires at least (1) 45 minute walk/play session per day. Only takes short napsHigh - Needs multiple runs per day, high play drive, struggles to sleep during the day.
Any other thoughts regarding your dog's energy level, personality, and engagement throughout the day?
What brand and type of food do you feed this dog?*
Please include dry and canned, if applicable.
What percentage of protein (per dry matter basis) is contained in the dog's food? (dry food only)*
See food packaging or online reference for percentage.
This diet is:*

Grain-inclusiveGrain free
How much do you feed per meal?*
How many meals are fed per day?*
If you add any supplements to your dog's food, please list them here:
If your dog has any food allergies or sensitivities, please list them here:
Describe your dog's appetite:*

GoodPoor
How would you describe your dog's appetite for typical pet treats?*

Never eats pet treats.Very picky about treats, but will slowly eat one.May take it, then drop it, then eat it.A little picky with treats. Gets excited and eats them politely.Likes all treats. Gets excited, but is polite about taking them.Eats anything. Snatches treats, may bite hand in the process.
How would you describe your dog's appetite for people food?*

Never interested.Very picky, but will reliably eat a couple things.A little picky - may need to be hand fed.Likes some people food - mostly cheeses, meats, some crunchy fruits/vegetables.Loves people food! Will only refuse a few specific foods.Loves people food! Will snatch and steal anything/everything.
Has your dog ever eaten any other brands or types of food? Describe response to behavior and GI health. *
Please check ALL that apply regarding your dog's licking behavior.*

No excessive licking.Chews or licks furniture, carpet, bedding, etc.Chews or licks doors, walls, laminate, hardwood, etc.Excessively licks peopleExcessively licks self
Please check ALL that apply regarding your dog's non-food item chewing or consumption.*

Never eats non-food items.Eats a small amount of grass periodically.Eats grass frequently and can be redirected.Eats grass frequently and is difficult to redirect.Has an intense fixation for eating grass, difficult to redirect.Consumes small parts of their chews/bones.Consumes large chunks of their chews/bones.Consumes found/stolen objects.

Does your dog ever consume/eat any of the following:*

Rows	No	Yes	If Yes, how often does this occur?
Eats their own feces
Eats other household dogs' feces
Eats household cats' feces (litter box raiding)
Eats wild animals' feces

Please provide any additional details or comments regarding your dog's eating, chewing, licking, or other oral habits.
Does your dog ever experience abdominal heaving that results in vomiting?*

YesNo
If yes to vomiting, please check all that apply:*

Occurs every day.Occurs 3-4 times per week.Occurs 1-2 times per week.Occurs 4-5 times throughout the month.Vomiting occurs, but is very rare.Vomitus contains only bilious (yellow) or clear fluid.Vomitus contains small amounts of undigested food.Vomitus contains large quantities of undigested food.Vomitus contains non-food items.
Does your dog ever experience spitting up that does NOT involve abdominal heaving (regurgitation)?*

YesNo
If yes to regurgitation, please check all that apply:*

Occurs every day.Occurs 3-4 times per week.Occurs 1-2 times per week.Occurs 4-5 times throughout the month.Regurgitation occurs, but is very rare.Vomitus contains only bilious (yellow) or clear fluid.Vomitus contains small amounts of undigested food.Vomitus contains non-food items.Vomitus contains large quantities of undigested food.
Does your dog experience other upper GI symptoms? Please check all that apply.*

NoneEpisodes of increased frequency of swallowing.Episodes of swallowing hard, but not increased frequency.Gagging without any vomit production.Excessive lip licking.DroolingLip smackingExcessive burping
Please provide any other details regarding your dog's upper GI symptoms:
Does your dog experience soft stools or diarrhea?*

YesNo
If yes, please check all that apply:*

Occurs every day.Occurs 3-4 times per week.Occurs 1-2 times per week.Occurs 4-5 times throughout the month.Occurs 3-5 times per year.Occurs, but is very rare.Can be accompanied by vomiting.Can identify a specific cause (ex: dietary indiscretion)Requires veterinary treatment to resolve.Episodes accompanied by bright red blood.Episodes accompanied by dark red blood.Episodes accompanied by mucous.Episodes occur with increased urgency and frequency to defecate.

Using the above as a guide, what percentage of the time do you see the following fecal scores?*

Rows	1	2	3	4	5	6	7
Percentage

Check ALL items that pertain to your dog's defecation ritual:*

Very flexible with their toileting locations. No special preferences.Refuses to defecate anywhere but our yard.Refuses to defecate anywhere but on a walk.They sniff for a couple seconds before posturing to defecate.Walks slowly or "freezes" as they prepare to defecate.Their behavior is very frenetic or frantic before defecating.They need to circle multiple times before defecating.They get "distracted" from defecating easily.They vocalize while defecating.When done defecating, they walk away.When done defecating, they turn around and smell their excrement.When done defecating, they scratch the ground with their back feet.When done defecating, they immediately run away.They remain agitated for an extended period after defecating.
Does your dog demonstrate excessive flatulence?*

YesNoSometimes
Does your dog demonstrate excessive burping?*

YesNoSometimes
Does your dog demonstrate excessive belly sounds?*

YesNoSometimes
Please provide any other details about your dog's lower GI symptoms:
Is your dog showing signs of: (please check all that apply)*

Slowing down on walksLimping after exerciseSlow to rise from lying downDifficulty jumping up (onto furniture or into a vehicle)Feeling stiffDifficulty going up and down stairsDifficulty chasing objects/toysDifficulty runningNone of the above
Has your dog ever been diagnosed with pain or arthritis?*

YesNo
Has your dog ever been prescribed pain medication? (ex. gabapentin, Rimadyl, Previcox, Metacam, Galliprant, etc.)*

YesNoI don't know
Why was it prescribed?*
Should be Empty:

Rows	Name	dose (if known)	Response
product/medication
product/medication
product/medication
product/medication