Dog's Name _________________ Breed or type________________

Date of Birth ___/___/___ Current Age ______ Sex ______ Altered? Y/N

Date of last season ____/____/____

Owner's Name(s) _________________________________________________

Address _______________________________________________________

_______________________________________________________________

Telephone (h) ____/_________ (w) ____/_________(name) (w) ____/__________ (name)

If we can't reach you, is there someone we should call to act in your behalf in case of emergency? Y/N
If yes, name ______________________________Telephone ______/______-______

Name of Veterinarian _________________ Animal Hospital _____________

Telephone Number ___/_____________

Is your dog currently taking any medications or supplements? Y/N Please include information on heartworm, flea preventatives, vitamins, homeopathic or "natural" supplements. Please give name, dosage and frequency:
_____________________________________________________________________

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Has your dog had any of the following: If so, please circle and note date of last occurrence.


lameness
mites
"hot spots"
anal gland infection/problem
ear infections
dermatitis/specific
allergies
bloat/torsion
internal parasites
external parasites
vomiting
diarrhea
coughing/choking
heart murmur
surgery (except spay/neuter)
epilepsy (date of last observed seizure)____/____/____
hematomas
warts

Date of last inoculation:
rabies: ____/____/____

dhlpp:____/____/____

bordatella:____/____/____

Please describe any other health problem, or give further information on the back of the sheet.

_____________________________________________________________________

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Is your dog friendly with all people? Y/N Is he friendly with people only after he gets to know them? Y/N

Does your dog seem to worry about people with beards, hats, uniforms? Y/N Other? _______

Is your dog vocal? Y/N If so, when? _____________________ Is he/she quiet in the crate? Y/N

Does your dog like/love to chew? Y/N What does he most like to chew? ________________

He/she really likes it when: (rub ears, sing to him, back rub, tummy massage, etc.) ___________

His/her favorite game is: __________________________________________________________

He/she doesn't like: (ear cleaning, nail trim, being picked up, coat brushing, car rides) _____________________________________________________________________________

He/she can be frightened by: (thunder , loud noises, vacuum cleaner, etc.) ___________________

Is your dog crated in your absence? Y/N If so, what cue phrase do you use? _________________

Does your dog have a specific word or phrase as an elimination cue? ________________________

Please describe any incidents of aggression you have experienced. Please include biting, growling, snapping or any threatening body language that you noticed.________________________________

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Describe any "arguments" he/she may have had with other dogs: ___________________________