Type:

Age:

Gender:

Breed:

Spayed/Neuted:

Regular Vet:

Microchip:

Microchip no. :

Has this pet ever been to the veterinarian for any medical problems?

Yes No

Has this pet needed medical treatment now or in the past?

Yes No

Is this pet currently on any medication or prescription food?

Yes No

Has this pet ever exhibited excessive licking or scratching?

Yes No

Has this pet ever had any eye or ear problems?

Yes No

Has this pet ever had severe vomiting or diarrhoea?

Yes No

Does this pet have difficulty rising or walking?

Yes No

Does this pet have any physical abnormalities?

Yes No

Has this pet had any behavioural problems?

Yes No

Has this pet ever been used in competitive or commercial activities?

Yes No

Are all vaccinations up to date?

Yes No

If you answered yes to any of these questions, please provide details: