PHR-English-Adult



|A. Owner’s Identification B. Dog’s Identification/Breeder’s Info |

|Owner’s Name (Last, First, MI) |Call Name |

|      |      |

|Co-Owner’s Name (Last, First, MI) |Registered Name |

|      |      |

|Owner’s Address |Permanent Identification (Microchip #) |

|      |      |

|City |State |Zip |Country |Breed |

|      |      |      |      |      |

|Co-Owner’s Address |Date of Birth |Date Purchased/Adopted |

|      |      |      |

|City |State |Zip |Country |Color |Sex |

|      |      |      |      |      |Male Female Neutered |

|Home Phone |Work Phone |Breed Registration Number |

|      |      |      |

|Cell Phone |Email Address |Rabies Tag Number |

|      |      |      |

|Additional Contacts for Urgent Care |Sire’s Registered Name |Sire’s Call Name |

|      |      |      |

|Handler/Agent Name (Last, First) |Dam’s Registered Name |Dam’s Call Name |

|      |      |      |

|Address |Breeder |

|      |      |

|City, State |Zip |Breeder’s Kennel Name |

|      |      |      |

|Home Phone |Work Phone |Breeder’s Address |

|      |      |      |

|Cell Phone |Email Address |City |State |Zip Code |Country |

|      |      |      |      |      |      |

|Breed Health Question Contact |Home Phone |Work Phone |

|      |      |      |

|Email Address |Cell Phone |Email Address |

|      |      |      |

|Phone Numbers |Co-Breeder’s Name |

|      |      |

|Breed Health Question Contact |Address |

|      |      |

|Phone/Email |Phone |Email |

|      |      |      |

| |

|C. Veterinarians/Pet Care Providers |

|Specialty Primary Care Emergency |Phone |Emergency Phone |

|Reproduction Rehab Holistic Medicine |      |      |

|Name |Email Address |

|      |      |

|Group or Association |Fax |

|      |      |

|Address |Web Address/URL |

|      |      |

|City |State |Zip Code | |

|      |      |      | |

|Specialty Primary Care Emergency |Phone |Emergency Phone |

|Reproduction Rehab Holistic Medicine |      |      |

|Name |Email Address |

|      |      |

|Group or Association |Fax |

|      |      |

|Address |Web Address/URL |

|      |      |

|City |State |Zip Code | |

|      |      |      | |

|Specialty Primary Care Emergency |Phone |Emergency Phone |

|Reproduction Rehab Holistic Medicine |      |      |

|Name |Email Address |

|      |      |

|Group or Association |Fax |

|      |      |

|Address |Web Address/URL |

|      |      |

|City |State |Zip Code | |

|      |      |      | |

|Specialty Primary Care Emergency |Phone |Emergency Phone |

|Reproduction Rehab Holistic Medicine |      |      |

|Name |Email Address |

|      |      |

|Group or Association |Fax |

|      |      |

|Address |Web Address/URL |

|      |      |

|City |State |Zip Code | |

|      |      |      | |

| |

|D. Insurance |

|Insurance Provider Type |

|      |

|Company Name |

|      |

|Address |Agent |

|      |      |

|City |State |Zip Code |Phone |

|      |      |      |      |

|Plan Number |Fax |

|           |      |

| |

|E. Medical History(Check appropriate) |

|Condition |Date of Onset |Resolved |Date Resolved |

| |Lameness |      | Yes | No |      |

| |Rash |      | Yes | No |      |

| |Intestinal Parasites |      | Yes | No |      |

| |Cough |      | Yes | No |      |

| |Ear Infection |      | Yes | No |      |

| |Eye Infection |      | Yes | No |      |

| |Urinary Incontinence |      | Yes | No |      |

| |Urinary Tract Infection |      | Yes | No |      |

| |Diarrhea |      | Yes | No |      |

| |Constipation |      | Yes | No |      |

| |Poor Appetite |      | Yes | No |      |

| |Lethargy |      | Yes | No |      |

| |Bloat |      | Yes | No |      |

| |Spenic Torsion |      | Yes | No |      |

| |Seizures |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |      |      | Yes | No |      |

| |

|F. Immunizations |

|Immunization for |Date |Date |Date |Date |Date |Date |

|Canine Parvovirus |      |      |      |      |      |      |

| |      |      |      |      |      |      |

|Canine Distemper Virus |      |      |      |      |      |      |

| |      |      |      |      |      |      |

|Canine Adenovirus |      |      |      |      |      |      |

| |      |      |      |      |      |      |

|Rabies |      |      |      |      |      |      |

| |      |      |      |      |      |      |

|Parainfluenza Virus |      |      |      |      |      |      |

| |      |      |      |      |      |      |

|Bordetella bronchiseptica |      |      |      |      |      |      |

| |      |      |      |      |      |      |

|Borrelia burgdorferi (Lyme Disease) |      |      |      |      |      |      |

| |      |      |      |      |      |      |

|Leptospira interrogans |      |      |      |      |      |      |

| |      |      |      |      |      |      |

|Porphyromonas sp (periodontal disease) |      |      |      |      |      |      |

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|      |      |      |      |      |      |      |

| |      |      |      |      |      |      |

| |

|G. Allergies/Drug Sensitivities |

|Allergy/Sensitivity Type (include medications| | | |

|foods environmental or other) |Reaction |Date last Occurred |Treatment |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

| |

|H. Family/Pedigree Health Concerns |

| Epilepsy/Seizures |Description |Affected Relatives |

| |      |      |

| |Description |Affected Relatives |

|Cancer |      |      |

| Joint Diseases |Description |Affected Relatives |

| |      |      |

| Splenic Torsion |Description |Affected Relatives |

| |      |      |

| |Description |Affected Relatives |

|Bloat |      |      |

| |Description |Affected Relatives |

|Allergies |      |      |

| |Description |Affected Relatives |

|Hernia |      |      |

| |Description |Affected Relatives |

|Eye Problems |      |      |

| |Description |Affected Relatives |

|Other |      |      |

| |Description |Affected Relatives |

|Other |      |      |

| |

| |

|I. Health Log (Major Illnesses) |

| | | | | | |

|Date Diagnosed |Vet |Illness |Age at Onset |Status |Comments |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

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|      |      |      |      |      |      |

| |

|J. Medications |

|Note: Include all prescription medications, over-the-counter medications (taken on a regular basis), vitamin supplements, and herbal remedies |

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|K. Veterinarian Outpatient Visits |

|Date |Veterinarian |Reason |Remarks |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

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| |

|L. Hospitalizations/Surgeries |

|Hospitalization Type (Elective, Emergent, etc) |Diagnosis |

|      |      |

|Admission Date |Discharge Date |Treatment |

|      |      |      |

|Veterinarian |Outcome |

|      |      |

|Hospitalization Type |Diagnosis |

|      |      |

|Admission Date |Discharge Date |Treatment |

|      |      |      |

|Veterinarian |Outcome |

|      |      |

|Hospitalization Type |Diagnosis |

|      |      |

|Admission Date |Discharge Date |Treatment |

|      |      |      |

|Veterinarian |Outcome |

|      |      |

|Hospitalization Type |Diagnosis |

|      |      |

|Admission Date |Discharge Date |Treatment |

|      |      |      |

|Veterinarian |Outcome |

|      |      |

|Hospitalization Type |Diagnosis |

|      |      |

|Admission Date |Discharge Date |Treatment |

|      |      |      |

|Veterinarian |Outcome |

|      |      |

|Hospitalization Type |Diagnosis |

|      |      |

|AdmissionDate |Discharge Date |Treatment |

|      |      |      |

|Veterinarian |Outcome |

|      |      |

|Hospitalization Type |Diagnosis |

|      |      |

|AdmissionDate |Discharge Date |Treatment |

|      |      |      |

|Veterinarian |Outcome |

|      |      |

| |

| |

|M. Lab Tests |

|Test Type |Date |Test Type |Date |

|      |      |      |      |

|Requesting Vet |Administered by |Requesting Vet |Administered by |

|      |      |      |      |

|Reason |Reason |

|      |      |

|Result |Result |

|      |      |

|Test Type |Date |Test Type |Date |

|      |      |      |      |

|Requesting Vet |Administered by |Requesting Vet |Administered by |

|      |      |      |      |

|Reason |Reason |

|      |      |

|Result |Result |

|      |      |

|Test Type |Date |Test Type |Date |

|      |      |      |      |

|Requesting Vet |Administered by |Requesting Vet |Administered by |

|      |      |      |      |

|Reason |Reason |

|      |      |

|Result |Result |

|      |      |

| |

|N. Imaging (Examples: X-ray, MRI, Ultrasound) |

|Test Type |Date |Test Type |Date |

|      |      |      |      |

|Requesting Vet |Administered by |Requesting Vet |Administered by |

|      |      |      |      |

|Reason |Reason |

|      |      |

|Result |Result |

|      |      |

|Test Type |Date |Test Type |Date |

|      |      |      |      |

|Requesting Vet |Administered by |Requesting Vet |Administered by |

|      |      |      |      |

|Reason |Reason |

|      |      |

|Result |Result |

|      |      |

| |

|O. Physical Therapy/Rehab |

| | | | | |

|Therapy Type |Start Date |Stop Date |Frequency |Therapist |

|      |      |      |      |      |

|      |      |      |      |      |

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|P. Dental Health |

|Date of Visit |Vet |Problems |Resolution |

|      |      |      |      |

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|Q. Health Clearances |

| Hips (OFA) |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

|      |

| Hips (PennHip) |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

|      |

| Shoulders |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

|      |

| Elbows |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

|      |

| Patella |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

|      |

| Cardiac |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

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| Eye (CERF) |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

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| Eye (CERF) |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

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| Eye (CERF) |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

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| Eye (CERF) |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

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| Other |Reference Number |Date of Test |Vet |

| |      |      |      |

|Test Results |

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|R. Reproductive Health/Breeding - Bitches |

|Heat Cycle Start |Heat Cycle End |Hormone Testing |Comments |

| | |Day # |Result | |

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|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|Dates Bred & Method |Stud Dog Information |

|      |Owner |Owner ‘s Phone |

| |      |      |

|      |Dog’s Name |Owner’s Address |

| |      |      |

|      |Stud Dog Registration # |Stud Dog DNA # |

| |      |      |

|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |

|      |      |      |      |

|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |

|      |      |      |      |

|Whelping Details |

|      |

| |

|Dates Bred & Method |Stud Dog Information |

|      |Owner |Owner ‘s Phone |

| |      |      |

|      |Dog’s Name |Owner’s Address |

| |      |      |

|      |Stud Dog Registration # |Stud Dog DNA # |

| |      |      |

|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |

|      |      |      |      |

|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |

|      |      |      |      |

|Whelping Details |

|      |

| |

|Dates Bred & Method |Stud Dog Information |

|      |Owner |Owner ‘s Phone |

| |      |      |

|      |Dog’s Name |Owner’s Address |

| |      |      |

|      |Stud Dog Registration # |Stud Dog DNA # |

| |      |      |

|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |

|      |      |      |      |

|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |

|      |      |      |      |

|Whelping Details |

|      |

| |

|S. Reproductive Health/Breeding - Dogs |

|Semen Evaluation Dates |Semen Evaluation Results |

|      |      |

|      |      |

|      |      |

|Frozen Semen Storage/Use |

|Facility |Collection Date |Lot/Tracking # |Date Used |Brood Bitch |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|Dates Bred & Method |Brood Bitch Information |

|      |Owner |Owner ‘s Phone |

| |      |      |

|      |Bitch’s Name |Owner’s Address |

| |      |      |

|      |Bitch’s Registration # |Bitch’s DNA # |

| |      |      |

|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |

|      |      |      |      |

|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |

|      |      |      | |

|Litter Details |

|      |

| |

| |

| |

| |

|Dates Bred & Method |Brood Bitch Information |

|      |Owner |Owner ‘s Phone |

| |      |      |

|      |Bitch’s Name |Owner’s Address |

| |      |      |

|      |Bitch’s Registration # |Bitch’s DNA # |

| |      |      |

|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |

|      |      |      |      |

|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |

|      |      |      |      |

|Litter Details |

|      |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Dates Bred & Method |Brood Bitch Information |

|      |Owner |Owner ‘s Phone |

| |      |      |

|      |Bitch’s Name |Owner’s Address |

| |      |      |

|      |Bitch’s Registration # |Bitch’s DNA # |

| |      |      |

|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |

|      |      |      |      |

|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |

|      |      |      |      |

|Litter Details |

|      |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Dates Bred & Method |Brood Bitch Information |

|      |Owner |Owner ‘s Phone |

| |      |      |

|      |Bitch’s Name |Owner’s Address |

| |      |      |

|      |Bitch’s Registration # |Bitch’s DNA # |

| |      |      |

|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |

|      |      |      |      |

|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |

|      |      |      |      |

|Litter Details |

|      |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Dates Bred & Method |Brood Bitch Information |

|      |Owner |Owner ‘s Phone |

| |      |      |

|      |Bitch’s Name |Owner’s Address |

| |      |      |

|      |Bitch’s Registration # |Bitch’s DNA # |

| |      |      |

|Pregnancy Confirmed On |Confirmation Method |Expected Whelp Date |Estimated Litter Size |

|      |      |      |      |

|Actual Whelp Date |# Puppies Whelped |# Live Puppies |# Nonviable Puppies |

|      |      |      |      |

|Litter Details |

|      |

| |

| |

| |

| |

| |

| |

| |

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