Health Information Form-for Dogs

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’sAddress
Cell Phone / Email Address / City / State / Zip Code / Country
Breed HealthQuestion 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
Reproduction Rehab Holistic Medicine / Phone / Emergency Phone
Name / Email Address
Group or Association / Fax
Address / Web Address/URL
City / State / Zip Code
Specialty Primary Care Emergency
Reproduction Rehab Holistic Medicine / Phone / Emergency Phone
Name / Email Address
Group or Association / Fax
Address / Web Address/URL
City / State / Zip Code
Specialty Primary Care Emergency
Reproduction Rehab Holistic Medicine / Phone / Emergency Phone
Name / Email Address
Group or Association / Fax
Address / Web Address/URL
City / State / Zip Code
Specialty Primary Care Emergency
Reproduction Rehab Holistic Medicine / Phone / Emergency Phone
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)
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
Cancer / Description / Affected Relatives
Joint Diseases / Description / Affected Relatives
Splenic Torsion / 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 / Description / Affected Relatives
I.Health Log (Major Illnesses)
Date Diagnosed / Vet / Illness / Age at Onset / Status / Comments
J. Medications
Note: Include all prescription medications, over-the-counter medications (taken on a regular basis), vitamin supplements, and herbal remedies
K. Veterinarian Outpatient Visits
Date / Veterinarian / Reason / Remarks
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
P. Dental Health
Date of Visit / Vet / Problems / Resolution
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
Eye (CERF) / Reference Number / Date of Test / Vet
Test Results
Eye (CERF) / Reference Number / Date of Test / Vet
Test Results
Eye (CERF) / Reference Number / Date of Test / Vet
Test Results
Eye (CERF) / Reference Number / Date of Test / Vet
Test Results
Other / Reference Number / Date of Test / Vet
Test Results
R. Reproductive Health/Breeding - Bitches
Heat Cycle Start / Heat Cycle End / Hormone Testing / Comments
Day # / Result
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