Canine Medical History
Animal Name __________________________________________ Client Name_____________________________________________
Dog Breed _____________________________________________ DOB ___________________________ Male/Female ___________
Color _________________________________________________ Altered _______________
Reactions Special Notes
______________________________________________________ _______________________________________________________
______________________________________________________ _______________________________________________________
______________________________________________________ _______________________________________________________
______________________________________________________ Diet ___________________________________________________
Interval Last
Mos. Vaccine 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
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| Lepto 4 Sero. |
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| Rabies |
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| Lyme |
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| Bordetella |
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| Flea/Tick Prev. |
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| H/W Prev. |
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| H/W Occult |
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| Fecal |
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| Weight |
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Date Surgical Procedure Date Dental Procedure
___________ _______________________________________ ___________ _________________________________________
___________ _______________________________________ ___________ _________________________________________
___________ _______________________________________ ___________ _________________________________________
Date Medical Problem Medication Mg Dosage Refills Thru
___________ _______________________________________ __________________ _____ _______________ _________
___________ _______________________________________ __________________ _____ _______________ _________
___________ _______________________________________ __________________ _____ _______________ _________
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