Canine History Form Owner*Date* Date Format: MM slash DD slash YYYY Pet Name*Breed*ColorAgeSex*MaleMale (Neutered)FemaleFemale (Spayed)About Your DogYour dog was obtained from*BreederPet storeFriendStrayHumane Soc.Your dog is*IndoorOutdoor - free roamingBothNumber of dogs in household*Brand of pet food*Canned/DryCannedDryHow is your dog's appetite*NormalHow is your dog's attitude*Happy-Active-NormalDepressed-LethargicIs your dog drinking*NormallyMoreLess 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 HistoryPrevious veterinary hospital:May we request your records from their office?*YesNoFirst visit to a veterinarianHas your dog had the following in the last 12 months:Physical examination*YesNoUnsureDate of last exam*Dental examination and cleaning*YesNoUnsureDate of last exam*Heartworm test*YesNoUnsureDate of last exam*Fecal sample test*YesNoUnsureDate of last exam*Blood testing for thyroid, kidney & liver function*YesNoUnsureDate of last exam*Has your dog been vaccinated for the following in the last 12 monthsRabies*YesNoUnsureDate of last vaccination*Canine Distemper*YesNoUnsureDate of last vaccination*Lyme disease*YesNoUnsureDate of last vaccination*Canine cough*YesNoUnsureDate of last vaccination*Has your dog been dewormed in the last 12 months*YesNoUnsureDate*Flea & tick preventative(s)Heartworm preventativeAre you familiar with geriatric care for dogs over 7 years of ageYesNoCurrent medications and allergiesComments