Ervets4pets.com - Canine Medical History Form

Canine Medical History Form
Patient/Owner Information
Patient name*
Date*

MonthDayYear
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?*

YesNo
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?*
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 describe
Has your dog had a recent blood work?*

YesNo
If yes, when?*
Was it normal?*

YesNo
Please list the abnormalities
Is your dog on heart worm prevention?*

YesNo
If so, what kind and frequency?
Is your dog on flea/tick prevention?*

YesNo
If so, what kind and frequency?*
Does your dog have any known allergies?*

YesNo
If So, Describe*
Is your pet being seen for vomiting and/or diarrhea?*

YesNo
Is your dog on any medications?*

YesNo
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?*
How is your dog’s appetite (normal, increased, decreased, anorexic)?*

normalincreaseddecreasedanorexicOther
How is your dog’s attitude (happy-active-normal, depressed/lethargic, other)?*

Happy active-normalDepressed lethargicOther
How is your dog’s water intake (normal, increased, decreased)?*

normalincreaseddecreasedOther
Have you seen any of the following symptoms?*

Nasal DischargeSneezingEye DischargeLethargyStraining to UrinateStraining to DefecateVomitingDiarrheaCoughingLimpingHair LossSkin Masses/LumpsScratchingWeight LossSeizuresWeakness/CollapseParalysisVocalizingShaking headScootingIncreased Rate or Effort with BreathingNoneOther
Does your pet appear to be in pain?*

YesNo
Additional Comments*
Should be Empty:

Canine Medical History Form

Patient/Owner Information

About Your Dog

Your Dog’s Medical History

Presenting Complaint