Official pedigree name:

Date of Birth:

If your dog has been vaccinated in the last 12 months, please tick against all the diseases that apply below:

Distemper (DHP), Parvovirus, Adenovirus, ParainfluenzaLeptospirosis (Nobivac Lepto 2)Leptospirosis (Nobivac Lepto 4)Kennel CoughRabies

When was your dog last wormed, and with which brand (if you can remember):

Has your dog been spayed or neutered and, if so, when?:

What do you currently feed your dog:

How many meals per day:

How much food in weight per day:

How much does your dog weigh in pounds:

How many hours of exercise (walk or training but not including time in the garden) does your dog get each week?:

How many hours are off the lead:

Has your dog developed any behavioural problems in the last 12 months?

If your dog has been to the vet for any injuries or illnesses in the last 12 months, please provide details:

If you have treated your dog at home for any health problems in the last 12 months, please provide details:

On a scale from 1 - 5 where 5 is great (happy, relaxed, excited) and 1 is poor (scared, nervous or aggressive), how well does your dog now react around:

1. Children

2. Strangers visiting the house

3. Strangers outside (on a walk or somewhere public)

4. Around other dogs they don't know

5. In traffic

Comments (Please use this last field to tell us anything you think we might like to know about your dog concerning the last 12 months)