JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Dog Veterinary History
Please complete this form so that we can better understand your prospective Service Dog's health:
* Indicates required question
Email
*
Your email
Your Name:
*
Your answer
Address:
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
Phone:
*
Your answer
Your Dog's Name:
*
Your answer
Dog's Breed:
*
Your answer
Dog's Age:
*
Your answer
Dog's Sex:
*
Female, intact
Male, intact
Female, neutered
Male, neutered
Other:
Veterinarian's Name:
*
Your answer
Veterinarian's Address:
*
Your answer
Date of Last Veterinary Exam:
*
MM
/
DD
/
YYYY
Vaccination History (which vaccines received, including dates):
*
Your answer
Date of Last Negative Fecal Exam:
*
MM
/
DD
/
YYYY
Preventative Medicines for Fleas, Ticks, and Worms (please include names of medications and frequency given):
*
Your answer
Has your dog had any medical problems? Please elaborate:
*
Your answer
Do you have any concerns about your dog's health at this time? Please elaborate:
*
Your answer
Is your dog either over-weight or under-weight? Please describe your dog's weight-related fitness:
*
Your answer
Please describe your dog's diet and feeding schedule including type and amount of food and treats given each day, and times of feeding:
*
Your answer
Does your dog finish meals?
*
Yes, and quickly
Yes, but takes her time
Yes, he free feeds and eats when he wants to
Sometimes he doesn't finish his meals
She often doesn't finish her meals
We have to coax him to eat
Who feeds your dog?
*
Me
My Spouse
My Child
Someone Else
We Take Turns
Where does your dog eat?
*
Your answer
Does your dog ever eat non-food items? If so, please elaborate:
*
Your answer
Is your dog ever defensive of food, bones, toys, or other items? Please elaborate:
*
Your answer
How much water is your dog given, and how frequently?
*
Your answer
Where is your dog's water bowl located?
*
Your answer
Are there times when your dog's access to water is restricted? Please elaborate:
*
Your answer
Has your dog ever had a urinalysis?
*
Yes
No
Maybe
Has your dog ever had a urinary tract infection?
*
Yes
No
Maybe
Does your dog have any health issues related to elimination (urine or feces)? If yes, please elaborate:
*
Your answer
How many times per day is your dog taken or allowed outside to eliminate?
*
Your answer
Will your dog eliminate while on a 4-6' leash?
*
Yes
No
Maybe
Do you have a fenced yard?
*
Yes
No
Do you always walk your dog to eliminate, or is she allowed outside by herself? Please elaborate:
*
Your answer
How many times per day does your dog urinate?
*
Your answer
How many times per day does your dog defecate?
*
Your answer
How much and what sorts of exercise does your dog get on a daily basis? Please elaborate:
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
