TABLE 7

DOG HISTORY (To be completed by owner)
Name:
Address:
Home 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
☐ Urinates in the house ☐ Defecates in house. ☐ Gets on furniture. ☐ Barks excessively	☐ Chews ☐ Jumps on people. ☐ Mouths people. ☐ Digs	☐ 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% house broken?		Yes No
How does the dog indicate a need to go out?
Volunteer/Owner Signature:		Date:

TO BE COMPLETED BY 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: