Owner's Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Phone

(###)

###

####

Date of birth *

Approximate

MM

DD

YYYY

Gender *

Male

Female

Male - Neutered

Female - Spayed

Where did you get your dog? *

Breeder/Pet Store

Animal Shelter/Rescue

Found as Stray

Family Member/Friend

Other

Why are you considering our facility for your dog? *

To play with other dogs/Socialization

Boarding

So not home alone

Doggie Day Care

Dog Park

Exercise

Recommended by another pet professional (vet, trainer, etc.)

Other

Which of the following best describes your dog's level of socialization with other dogs? *

None-no knowledge of dog interaction

Minimal-brief encounters while leashed

Moderate-some off-leash playtime on occasion with other dogs

More than Moderate-actively plays with other dogs off leash

Has your dog had any problems previously in an off-leash environment? *

If yes, please check all that apply

No

Yes - altercation or fight at a public dog park

Yes - altercation or fight with a neighbor or friend's dog

Yes - fearful reaction in a group of dogs

Yes - dismissed from a prior dog day care or social playgroup program (describe below)

Other (please describe)

Only complete if you answered "yes" that your dog was dismissed from a prior day care program.

What reason were you given as to why your dog was dismissed? Check each statement below that applies to the situation that resulted in your dog's dismissal.

My dog was injured; no medical treatment required

My dog was injured and required medical treatment

Another dog was injured; no medical treatment required

Another dog was injured and required medical treatment

A person was injured; no medical treatment required

A person was injured and required medical treatment

Does your dog have allergies? *

No

Yes

Does your dog have disabilities? *

Yes

No

Does your dog have a medical condition? *

Yes

No

Does your dog have any bathroom-related issues or concerns? *

Yes

No

Does your dog have any sensitive areas on his/her body where he/she would prefer not to be touched? *

Yes

No

Check the box that best describes your dog's overall level of exercise: *

Couch potato - spends days sleeping, occasional walks and/or playtime with humans or other dogs

Mild exerciser - short daily walks and/or regular playtime with humans or other dogs

Moderate exerciser - long or multiple walks daily and/or regular playtime with humans or other dogs

Athlete - Regular jogs/runs and/or reular participation in a dog sport activity such as agility, frisbee, etc.

Do visitors ever bring their dog(s) to your home? *

Yes

No

Does your dog ever bark or growl at a person or dog passing your home or yard? *

Yes

No

Are there any types and/or breeds of dog that your dog seems to automatically fear or dislike? *

Yes

No

Does your dog enjoy playing with other dogs? *

Yes

No

What commands does your dog know? *

Sit

Stay/wait

Down/off

Come

Heel

Roll Over

Shake

Other

How did your dog get his/her obedience training? *

Attended one group class

Attended more than one level of group classes (beginner, intermediate, Canine Good Citizen, etc.)

Dog was sent to board and train program

Private sessions in our home

None

Other

Which of the following best describes the use of obedience cues with your dog at home? *

Key part of daily communication

Used when we go on walks or have people over

Used occasionally to control behavior

Rarely used

Not used at all

How often does your dog jump on people? *

Frequently

Occasionally

Never

Does your dog have any problems with any of the following? *

Mouthing

Housetraining

Barking

Digging

Eating non-food items (rocks, feces, sticks, etc.)

Other

Has your dog ever growled at someone? *

Yes

No

Has your dog ever bitten a person? *

Yes

No

Has your dog ever bitten another animal? *

Yes

No

Has your dog ever climbed or jumped a fence? *

Yes

No

Has your dog ever escaped your house or yard? *

Yes

No

How would you describe your dog's level of energy? *

Low

Medium

High

Has your dog ever tried to chase a small animal (rabbit, squirrel, etc.)? *

Yes

No

Is your dog frightened of thunderstorms? *

Yes

No

Is your dog frightened or nervous around anything else? *

Yes

No

Does your dog play with toys? *

Yes

No

Has your dog ever growled or snapped at a person who has taken food or a toy away from him/her? *

Yes

No

Have you ever noticed your dog stopping and staring at another animal at any time? *

Yes

No