Annual Health Questionnaire
Urban Search & Rescue Canine
Date ____________________
Handler ________________________
Task Force ________________________
Address
________________________
________________________
Contact #’s ________________________
________________________
Canine __________________________
Breed __________________________
Color __________________________
Birth __________________________
Sex: Male M-Neuter Female F-Spay
Weight ________kg ________lb
Your answers are meant to provide the medical team with information to better assist
them in providing care for your canine should a problem arise during training or
deployment. Medical history is so important!
**If this is not the first time filling out the form, and nothing has changed, a copy of the
prior year may be used, but with new date and original signature.
Has your canine experienced, been diagnosed, and been treated for, or now have:
Cardiac System
Heart murmur
Heart arrhythmia
Heartworm positive
 Yes  No
 Yes  No
 Yes  No
Asymptomatic  Yes  No
Asymptomatic  Yes  No
If yes, resolved?  Yes  No
Dermatologic System (ears and skin)
Ear infection
 Yes  No
Dermatitis
 Yes  No
Chronic/recurrent?  Yes  No
‘Hot Spot’?
 Yes  No
Gastrointestinal System
Chronic vomiting
 Yes
Chronic diarrhea
 Yes
Colitis
 Yes
GDV (Bloat)
 Yes
 No
 No
 No
 No
If no, preventative gastropexy? Yes  No
Metabolic System
Frostbite
Heatstroke
Allergic reaction
Chronic allergy
Gland Disease
 No
 No
 No
 No
 No
If yes, to what? _______________________
(medicine, food, vaccine, insect bite, other)
(thyroid, adrenal, pituitary)
 Yes
 Yes
 Yes
 Yes
 Yes
Musculoskeletal System
Lameness
 Yes
Fracture/Luxation
 Yes
Sprain/strain/tear
 Yes
Clinical Dysplasia
 Yes
 No
 No
 No
 No
Neurologic System
Spinal/back problem  Yes  No
Seizure/collapse
 Yes  No
Ocular System
Conjunctivitis
Vision problem
Diagnosis________________________
Surgery Yes No Implants Yes  No
Surgery Yes No
Diagnosis?_______________________
 Yes  No
 Yes  No
Respiratory System
Difficulty breathing  Yes  No
Bronchitis/pneumonia  Yes  No
Diagnosis? _______________________
Urogenital System
UTI or Kidney Issues  Yes  No
(UTI = Urinary Tract Infection)
Prostate problem
 Yes  No  Not Applicable
Other
Separation Anxiety
Bleeding Disorder
Autoimmune Disease
Tick-borne Disease
Other Surgery
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
If any of the answers are yes, please provide a brief summary about the condition.
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Thank you for your time.
Handler Signature_______________________ Date________________________