Canine Medical History Form
Patient/Owner Information
Patient name
*
Date
*
-
Month
-
Day
Year
Date
Owner name
*
About Your Dog
How long have you had your dog?
*
Where did you get your dog (breeder, pet store, rescue, stray, friend, other)?
*
Is your dog indoor, outdoor or both?
*
How much time does he/she spend outside?
*
Number and Kind Of Pets in the Household
*
Diet (Brand, Canned/Dry, Amount, Frequency Of Feeding)
*
List Types and Amounts of Treats or Table Food
*
Has your dog recently traveled out of the area?
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Yes
No
If so, when and where?
Your Dog’s Medical History
Who is your dog’s primary care veterinarian/veterinary hospital?
*
When was the last time your dog was seen at a veterinarian?
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Has your dog been vaccinated and heart worm tested in the past 12 months?
*
Does your dog have any prior health concerns or conditions?
*
Please Select
Yes
No
Please describe
Has your dog had a recent blood work?
*
Yes
No
If yes, when?
*
Was it normal?
*
Yes
No
Please list the abnormalities
Is your dog on heart worm prevention?
*
Yes
No
If so, what kind and frequency?
Is your dog on flea/tick prevention?
*
Yes
No
If so, what kind and frequency?
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Does your dog have any known allergies?
*
Yes
No
If So, Describe
*
Is your pet being seen for vomiting and/or diarrhea?
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Yes
No
Is your dog on any medications?
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Yes
No
Please List All Current Medications (Name, Amount and Frequency) and Dosing Schedule
*
Presenting Complaint
What is going on?
*
When did it start?
*
When was the last time your dog was normal?
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How is your dog’s appetite (normal, increased, decreased, anorexic)?
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normal
increased
decreased
anorexic
Other
How is your dog’s attitude (happy-active-normal, depressed/lethargic, other)?
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Happy active-normal
Depressed lethargic
Other
How is your dog’s water intake (normal, increased, decreased)?
*
normal
increased
decreased
Other
Have you seen any of the following symptoms?
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Nasal Discharge
Sneezing
Eye Discharge
Lethargy
Straining to Urinate
Straining to Defecate
Vomiting
Diarrhea
Coughing
Limping
Hair Loss
Skin Masses/Lumps
Scratching
Weight Loss
Seizures
Weakness/Collapse
Paralysis
Vocalizing
Shaking head
Scooting
Increased Rate or Effort with Breathing
None
Other
Does your pet appear to be in pain?
*
Yes
No
Additional Comments
*
Submit
Should be Empty: