Dogs and Cats Information Form Animal's NameSpecies (Dog or Cat)BreedColorAgeDate of birth Date Format: MM slash DD slash YYYY Male or FemaleSpayed or neutered?Date of last vaccination:DistemperRabiesKennel CoughFel.LeukemiaLeptospirosisOther(please specify)Date of last stool sample and/or dewormingWormer usedDoes your dog or cat hunt or eat dead rodents or other animals?ls your dog on heartworm preventative? lf yes, which oneWhen did you give the last dose?Date of last heartworm blood testHas your pet ever lived in another state or country? lf so, where and when?Has your animal had any previous illnesses or ongoing problem? Please describels your animal on any supplements(including herbal and natural) or prescription medications? lf so which?What brand and type(canned or dry) of food does your dog/cat eat?How long has he/she been on this particular food?lf changed within last month or two, what was previous type of food?How many cups of dry per day?How many cans per day?Fed how many times per day?Previous surgeries (approximate dates)Reason for your visit todayDoes your pet liveindoors exclusivelyin and outoutdoors exclusively
