Canine Health History Form

Thank you for giving us the opportunity to care for your pet. To help us provide optimal healthcare, please take time to fill out this information.

Client Name(required) Client Email(required) Client Phone(required)

Pet's Name (required)

Birthdate/Age (required) Please Select (required)
ExactEstimated

Breed (required)

Color (required)

Please circle(required)
Intact FemaleSpayed FemaleIntact MaleNeutered Male

Please Circle how you would best describe your pet’s temperament for examination:(required)
FriendlyNervous/May BitePlease Muzzle/Will Bite

Please fill out the following information to the best of your ability. We can confirm much of this
information from previous records if they are available. If you have any questions about this
information, our veterinary technicians will assist you as they review your pet’s medical history.

Reason for Today’s Visit:

Current Medications/Supplements

Allergies/Allergic reactions

Current Diet

Date of Last Stool Check

Date of Last Deworming

Date of Last Heartworm Test

Did they also check for Lyme?
YesNo

Heartworm Preventative:
InterceptorHeartgard PlusRevolutionOther

Heartworm Prevention Used:
SeasonallyYear Round

When did you last apply flea/tick prevention?

Products Used:
FrontlineAdvantageRevolutionBioSpotHartzOther

Other

Most recent DHPP [Distemper Combo] Vaccination Date

Most recent Leptospirosis Vaccination Date (if applicable)

Most recent Bordetella (Kennel Cough) Vaccination Date (if applicable)

Most recent Lyme Vaccination Date (if applicable)

Most recent Rabies Vaccination Date

Vaccine Length:
3 Year2 Year1 Year

Does your dog travel out of the area? Where?

Do you have plans to board or travel in the next 6-12 months?
YesNo

Do you trim your dog’s nails?
YesNoWould like to learn

Do you brush your dog’s teeth?
YesNoWould like to learn

Date of last dental cleaning (if applicable)

Other Pets in Household (if applicable):
Cat(s)Dog(s)Other

Comments