Patient Information - Canine
Patient #__________________________ (Office use)
Patient's Name_____________________________________________
Breed___________________ Birthdate(approx.)___________________
Color____________________ Sex: Male ( ) Female ( )
Check here if your dog has been spayed or neutered? ( )
Please give the approx. age that your dog was spayed or neutered at_________
How did you acquire this dog? (Breeder, Pet Store, Friend, Humane Society, Newspaper Ad, etc. )_________________________________________
What does this dog get to eat?__________________________________
Does he/she get table foods?___________________________________
Does he/she get other treats?___________________________________
Has this dog ever been vaccinated for the following:
|
Distemper |
Yes ( ) No ( ) When__________________ |
|
Parvovirus |
Yes ( ) No ( ) When__________________ |
|
Coronovirus |
Yes ( ) No ( ) When__________________ |
|
Rabies |
Yes ( ) No ( ) When__________________ |
|
Lyme |
Yes ( ) No ( ) When__________________ |
Has your dog ever been tested for Heartworms?
If so, when was that done? _______________________
Is your pet currently on Heartworm preventative? Yes( ) No( )
What kind? ___________________________
Is your pet currently on a flea/tick preventative? Yes( ) No( )
If so, what kind?__________________
Has this dog ever had a stool sample checked for internal parasites?
Yes ( ) No ( )If so, when was that done? _______________________