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(954) 920-2400 | 521 N Federal Hwy, Hollywood, FL 33020

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Canine History Form

Owner*
Date*
Date Format: MM slash DD slash YYYY
Pet Name*
Breed*
Color
Age
Sex*
- Male
- Male (Neutered)
- Female
- Female (Spayed)
About Your Dog
Your dog was obtained from*
- Breeder
- Pet store
- Friend
- Stray
- Humane Soc.
Your dog is*
- Indoor
- Outdoor - free roaming
- Both
Number of dogs in household*
Brand of pet food*
Canned/Dry
- Canned
- Dry
How is your dog's appetite*
- Normal
How is your dog's attitude*
- Happy-Active-Normal
- Depressed-Lethargic
Is your dog drinking*
- Normally
- More
- Less than usual.
Do you notice any of the following
- Limping
- Eye Discharge
- Nasal discharge
- Sneezing
- Coughing
- Shaking head
- Scooting
- Scratching
- Vomiting
- Diarrhea
- Lumps
- Bad breath often
- Weight loss
- Lethargy / weakness
- Seizures
- Hair loss
Your Dog's Medical History
Previous veterinary hospital:
May we request your records from their office?*
- Yes
- No
- First visit to a veterinarian
Has your dog had the following in the last 12 months:
Physical examination*
- Yes
- No
- Unsure
Date of last exam*
Dental examination and cleaning*
- Yes
- No
- Unsure
Date of last exam*
Heartworm test*
- Yes
- No
- Unsure
Date of last exam*
Fecal sample test*
- Yes
- No
- Unsure
Date of last exam*
Blood testing for thyroid, kidney & liver function*
- Yes
- No
- Unsure
Date of last exam*
Has your dog been vaccinated for the following in the last 12 months
Rabies*
- Yes
- No
- Unsure
Date of last vaccination*
Canine Distemper*
- Yes
- No
- Unsure
Date of last vaccination*
Lyme disease*
- Yes
- No
- Unsure
Date of last vaccination*
Canine cough*
- Yes
- No
- Unsure
Date of last vaccination*
Has your dog been dewormed in the last 12 months*
- Yes
- No
- Unsure
Date*
Flea & tick preventative(s)
Heartworm preventative
Are you familiar with geriatric care for dogs over 7 years of age
- Yes
- No
Current medications and allergies
Comments

The Animal Medical Center & Bird Clinic of Hollywood

Phone: (954) 920-2400 Address: 521 N Federal Hwy, Hollywood, FL 33020

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