Owner/ Guardian name(s):
Mailing address:
Telephone:(
)
Alternate Telephone:(
Emergency Contact:
)
Email:
Contact Telephone:(
)
CANINE INFORMATION
Name:
Spayed/Neutered Y
Breed:
N
Age:
Weight:
Sex: M
F
Color:
Canine’s primary veterinary clinic(s)
Clinic
Veterinarian
Address
Telephone
Other current canine healthcare providers: chiropractic, acupuncture, physical
therapy, reiki, massage therapy, cranial sacral, etc.
Clinic/ Provider
Type of Treatment
Contact Information
Frequency of Visit
Were you referred by a healthcare provider? Yes/ No - If yes, by whom and for what
reason?
Canine Health History
Has your pet recently suffered from an injury? If so, when?
Has this injury been addressed by a veterinarian? If so, when?
Has your pet recently undergone surgery? If yes, type of surgery and date.
Current Medications?
Medication
Reason
How often
Does your pet suffer from any of the following: arthritis, obesity, heart disease, kidney
disease, liver disease, seizures, diabetes, cancer:
Does your pet receive any dietary supplements?
Does your dog suffer from:
Allergies (Food/Medication) Y / N
Skin disorders: Y / N
Incontinence: Y / N
Epilepsy: Y / N
Does your dog receive any topical medications?
Please describe any other pertinent medical conditions:
General
Is your pet here primarily for therapy or recreation?
How would you rate your dog’s swimming skills?
How does your dog respond to water? Does he/ she swim often?
What is your pet’s comfort level with a man made pool?
Does your dog enjoy:
Retrieving?
Toys? What kinds?
Treats? Permission to administer them?
Level of training: none simple commands agility obedience
service therapy hunting
What type of exercise does your dog participate in most frequently?
Temperament
How does your pet respond to being handled by strangers? Circle all that apply.
Shy
playful
fearful
submissive
unpredictable
stubborn
friendly
nervous
indifferent
skiddish
aggressive
flighty
excited
affectionate
How well-socialized is your pet with humans and other canines?
Briefly describe your dog’s strongest personality traits:
Does your pet have a history of:
Fear or aggression toward people? Y
N
Fear or aggression toward other dogs? Y
Finally…
N
Are there any special circumstances, or any emotional/ behavioral issues to be aware of in
order to ensure proper handling, and allow your pet more comfort & confidence in this
environment?
What are your goals for your pet?