Canine Health History Form

Primary Owner Name:

First NameLast Name

Email:

example@example.com

Patient Name:

Patient Date of Birth:

Date

Patient Sex:

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?

Primary (general practice) veterinary clinic:

Primary veterinary clinic phone number:

Please enter a valid phone number.Format: (000) 000-0000.

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:

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

Rabies vaccine date administered:

Rabies vaccine location administered (name of hospital or clinic):

Duration of rabies vaccine administered:

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):

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?

Please list ALL of the OTC behavior products or prescription medications your dog has taken in the past:

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

Any changes in eating or drinking within the last year?

Please explain the changes:

Has your dog presented with any of the following in the past year? Please check all that apply.

If you marked any of the above, please explain:

Has your dog ever had a seizure?

Has your dog had puppies?

How would you describe your dog's energy level?

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:

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:

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

How would you describe your dog's appetite for people food?

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.

Please check ALL that apply regarding your dog's non-food item chewing or consumption.

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?

If yes to vomiting, please check all that apply:

Does your dog ever experience spitting up that does NOT involve abdominal heaving (regurgitation)?

If yes to regurgitation, please check all that apply:

Does your dog experience other upper GI symptoms? Please check all that apply.

Please provide any other details regarding your dog's upper GI symptoms:

Does your dog experience soft stools or diarrhea?

If yes, please check all that apply:

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:

Does your dog demonstrate excessive flatulence?

Does your dog demonstrate excessive burping?

Does your dog demonstrate excessive belly sounds?

Please provide any other details about your dog's lower GI symptoms:

Is your dog showing signs of: (please check all that apply)

Has your dog ever been diagnosed with pain or arthritis?

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

Why was it prescribed?