Canine Patient History Form

Full Name*

Email*

Phone*

Format: (000) 000-0000.

Pet's Name*

Appointment Date/Time*

Reason For Visit *

Has your dog had any prior drug or vaccine reactions?*

YesNo

List Any Allergies *

Have you missed any doses of flea, tick, or heartworm prevention?*

YesNo

Please list all the current medications and supplements you give your dog (including heartworm, flea, & tick medications)*

Do you need any refills on the medications you listed?If so, please list the medication name, dosage, and quantity needed.*

What do you feed your dog? Please include brand, type (wet or dry), quantity, and feeding frequency. If your dog's diet is grain-free please include that as well. *

Does your dog live exclusively indoors, exclusively outdoors, or both?*

Does your dog travel with you? If so, please elaborate.*

Does your dog visit dog parks, daycare, groomers, or boarding facilities?*

Is your dog exposed to areas that have wildlife?*

YesNo

Have you seen fleas or ticks on your dog, or have you removed any over the last year?*

YesNo

Are there other household pets? If so, please list what kind and how many.*

Is your dog microchipped?*

YesNo

Does your dog resent being handled or picked up?*

YesNo

Is your dog fearful in any way?*

YesNo

Any coughing, sneezing, vomiting, or diarrhea? If so, please elaborate.*

Can you please bring a fresh stool sample from your dog to the appointment?*

YesNo

If your dog is an adult (1 year +), we recommend performing annual wellness bloodwork that also includes a stool sample, urinalysis, and heartworm test. Do we have your permission to perform these tests during the appointment?*

YesNo