Canine Health History Form
Richmond Campus
Primary Owner Name:
*
First Name
Last Name
Email:
*
example@example.com
Patient Name:
*
Patient Date of Birth:
*
-
Month
-
Day
Year
Date
Patient Sex:
*
Male, Intact
Male, Castrated
Female, Intact
Female, Spayed
Patient Breed:
*
Patient Weight (in pounds/lbs):
*
At which location are you requesting an appointment?
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Fairfax, VA Campus
Richmond, VA Campus
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 Name
Last Name
Date of last veterinary visit:
*
-
Month
-
Day
Year
Indicate any specialty veterinarian services your dog has received:
*
Behavior
Cardiology
Internal Medicine
Neurology
Dermatology
Ophthalmology
Orthopaedic
Oncology
Rehabilitation
None
Other
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?
*
Yes
No
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?
*
Yes
No
Please explain the changes:
*
Has your dog presented with any of the following in the past year? Please check all that apply.
Coughing
Sneezing
Vomiting
Diarrhea
Lumps
Bumps
Pain
Limping
None of the above
Other
If you marked any of the above, please explain:
*
Has your dog ever had a seizure?
*
Yes
No
Has your dog had puppies?
*
Yes
No
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 naps
High - 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-inclusive
Grain free
What is the amount and frequency you feed?
*
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:
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Good
Poor
How would you describe your dog's appetite for typical pet treats?
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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?
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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 people
Excessively 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
Daily
Weekly
Monthly
Rarely
Eats other household dogs' feces
Daily
Weekly
Monthly
Rarely
Eats household cats' feces (litter box raiding)
Daily
Weekly
Monthly
Rarely
Eats wild animals' feces
Daily
Weekly
Monthly
Rarely
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?
*
Yes
No
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)?
*
Yes
No
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.
Vomiting 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.
*
None
Episodes of increased frequency of swallowing.
Episodes of swallowing hard, but not increased frequency.
Gagging without any vomit production.
Excessive lip licking.
Drooling
Lip smacking
Excessive burping
Please provide any other details regarding your dog's upper GI symptoms:
Does your dog experience soft stools or diarrhea?
*
Yes
No
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?
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Yes
No
Sometimes
Does your dog demonstrate excessive burping?
*
Yes
No
Sometimes
Does your dog demonstrate excessive belly sounds?
*
Yes
No
Sometimes
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 walks
Limping after exercise
Slow to rise from lying down
Difficulty jumping up (onto furniture or into a vehicle)
Feeling stiff
Difficulty going up and down stairs
Difficulty chasing objects/toys
Difficulty running
None of the above
Has your dog ever been diagnosed with pain or arthritis?
*
Yes
No
Has your dog ever been prescribed pain medication? (ex. gabapentin, Rimadyl, Previcox, Metacam, Galliprant, etc.)
*
Yes
No
I don't know
Why was it prescribed?
*
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