BEHAVIOR MODIFICATION HISTORY FORM
Please fill out the following to the best of your ability. The more information you are able to give us that pertains to your dog, the better we will be able to help you.
= mandatory field
DOG INFORMATION (CONT.)
DATE OF LAST VACCINATION
DATE OF LAST COMPLETE VETERINARY CHECK UP
HAS VETERINARIAN NOTED ANY PHYSICAL PROBLEMS WITH THS DOG?
LIST PHYSICAL PROBLEMS NOTED BY VETERINARIAN
IS DOG TAKING ANY MEDICATION FOR MEDICAL PROBLEMS LISTED ABOVE?
LIST MEDICATION(S) DOG IS TAKING FOR MEDICAL PROBLEMS
BRAND OF HEARTWORM PREVENTATIVE DOG IS ON
IS DOG ON HEARTWORM PREVENTATIVE?
BRAND OF FLEA/TICK PREVENTATIVE DOG IS ON
IS DOG ON FLEA OR TICK PREVENTATIVE?
MEDICAL HISTORY
HOW MANY ANIMALS WERE IN YOUR PET'S LITTER?
ANY LITTERMATES AFFECTED WITH MEDICAL PROBLEMS?
IF YES, WHAT SPECIFICALLY?
ANY LITTERMATES AFFECTED WITH BEHAVIORAL PROBLEMS?
IF YES, WHAT SPECIFICALLY?
WHY DID YOU CHOOSE THIS SPECIFIC PUPPY FROM THE LITTER?
WHY DID YOU CHOOSE THIS SPECIFIC BREED?