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.

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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 LISTED

IS DOG ON HEARTWORM PREVENTATIVE?

BRAND OF HEARTWORM PREVENTATIVE DOG IS ON

IS DOG ON FLEA OR TICK PREVENTATIVE?

BRAND OF FLEA/TICK PREVENTATIVE DOG IS ON

MEDICAL HISTORY

HOW MANY ANIMALS WERE IN YOUR PET'S LITTER?

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ANY LITTERMATES AFFECTED WITH MEDICAL PROBLEMS?

ANY LITTERMATES AFFECTED WITH BEHAVIORAL PROBLEMS?

IF YES, WHAT SPECIFICALLY?

WHY DID YOU CHOOSE THIS SPECIFIC PUPPY FROM THE LITTER?

LITTER INFORMATION

WHY DID YOU CHOOSE THIS SPECIFIC BREED?

PET OWNERSHIP HISTORY

HAVE YOU OWNED THIS PARTICULAR BREED OR BREED CROSS BEFORE?

HAVE YOU OWNED PETS BEFORE?

HAVE YOU OWNED DOGS BEFORE?

HAVE YOU OWNED CATS BEFORE?

HAVE YOU OWNED BIRDS BEFORE?

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