Vetstreet-wb.brightspotcdn.com
Canine
Patient Information Sheet
Pets Name: _______________________________________________ Birth date/Age: __________________
Breed: _____________________________________________ Color: _______________________________
Sex: _____________________ Has your pet been spayed/neutered? Yes No
Diet
Brand of food being fed: ________________________________________ Dry Canned Soft
How many meals per day: _____________________________ How much per feeding: _________________
Is your pet fed free choice (food always available)? Yes No. How much per day: ________________ Is bowl empty by night? Yes No.
Do you give your dog treats? Yes No. What kind? _________________________________________ How many per day? ________________________
Lifestyle
What kind of activities does or will your dog participate in? (Check all that apply.)
Walks Boarding Dog shows
Neighborhood Doggie day care Therapy dog program
Public Park Hunting or Field trials Other________________
Wooded area, fields Obedience or Agility _____________________
Go to the groomer (classes or competition)
Does your dog get along with other pets? ____________________________________________________
What other pets share your household? _____________________________________________________
Do you have a Fenced yard Invisible fence Tie out or dog run?
Are there any rats, raccoons, deer, skunks, foxes, or coyotes in your area? ________________________
Medical History
Yes No
Has your dog had any major illness, surgery or medical problem? (Describe briefly on
back) ______________________________________________________________________
Is your dog currently receiving medications or supplements? ________________________
____________________________________________________________________________
Has your dog ever had any adverse reaction to medication or vaccinations? ____________
____________________________________________________________________________
Where has your pet received medical care in the past? ______________________________
May we contact them?
................
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