• Canine History Form

    The information you provide below will be used during your consultation to develop a diagnosis and plan of treatment. Please fill it out as completely as you can. All information will be held in strict confidence and will not be released to any third party without your written consent.

  • Please submit this form online at least 2 business days prior to your dog's appointment

  •  -  - Pick a Date

  • Your Contact Information

  • Your Family Veterinarian's Contact Information


  • Your Dog's Information

  •  -  -
    Pick a Date
  •  -  - Pick a Date

  • Behavior History

  •  -  - Pick a Date
  •  -  - Pick a Date

  • How long has this behavior been going on?

  • Medical History

  • Your Dog's Environment

    Please describe all the people living in the household now, starting with yourself:

  • Diet and Feeding

    Feeding
  •  :
  •  :
  •  :

  • Water

  • Other

  • Your Dog's Daily Routine

    Sleeping

  • Daytime

  • Exercise

  • Other Animals

  • Training

  • Your Dog's Interaction with People

  • For the following behaviors, please check one or more of the boxes under these descriptions:

    NR = no reaction
    M = mutter/grumble with mouth closed
    B = bark in a threatening manner
    G = growl with mouth closed, no teeth showing
    SL = snarl/rumble with teeth showing (mouth open or closed)
    SN = snapping, teeth close rapidly without contacting person
    BT = teeth close rapidly and contact person (may/may not leave mark)
    ND = never done

    ***IMPORTANT *** IF YOU HAVE NEVER DONE SOME OF THESE TASKS, DO NOT TRY THEM***

  •   NR M B G SL SN BT ND
    Take dog’s meal away while he/she is eating
    Add food to bowl while dog is eating
    Take away dog's favorite toy
    Pet the dog
    Trim dog's nails
    Lift or try to lift the dog
    Grab dog by collar
    Hug or kiss dog
    Scold dog verbally
    Restrain dog
    Push on dog's back
    Bathe dog
    Push on dog's rump
    Wash dog's face
    Wake dog when sleeping
  • Should be Empty: