RULES FOR HOSPITALS AND RELATED INSTITUTIONS IN ARKANSAS

TABLE 7

DOG HISTORY (To be completed by owner.)
Name:
Address::
Home Phone:		Work Phone:
Name of Veterinarian/Clinic:
Address of Veterinarian:
Name of Pet:		Breed:
Sex:	Age:	Weight:
Comment on how dog relates to people:
Men	Women	Children
Check the behaviors the dog has exhibited:
☐ Urinates in the house. ☐ Defecates in house. ☐ Barks excessively. ☐ Gets on furniture.	☐ Chews ☐ Jumps on people. ☐ Digs ☐ Mouths people.	☐ Been in dog fight. ☐ Chases cats/birds. ☐ Carsickness ☐ Other:
Does the dog dislike?
☐ Other dogs ☐ Tile or slippery floors.	☐ Cats ☐ Loud noises	☐ Strange objects ☐ Other:
Is the dog 100% housebroken? ☐ YES ☐ NO
How does the dog indicate a need to go out?
Volunteer/Owner Signature:		Date:

TO BE COMPLETED BY THE DOG'S REGULAR VETERINARIAN
Date of most recent exam:
DA2PP Vaccine		Rabies Vaccine
Fecal Exam:	Results: Floatation	Direct Smear:
Heartworm prevention medication:		Frequency:
What does the owner state he/she does for flea prevention?
Any major medical illness?
Is the dog currently on any medication? If so, list:
Date of last teeth cleaning:
Veterinarian Signature:		Date:

Table 7 - 1