| ABOUT YOU |
| Name: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Home Phone: |
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| Work Phone: |
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| Cell Phone: |
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| Email: |
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| ABOUT YOUR POOCH |
| Dog's Name: |
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| Sex: |
Male
Female
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| Age: |
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| Birthday: |
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| Breed: |
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| Color: |
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| VETERINARY |
| Dr. Name: |
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| Clinic Name: |
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| Clinic Phone: |
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| CURRENT VACCINATIONS (date last given) |
| DHLPP Month/Year: |
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| Rabies Month/Year: |
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| Bordatella Month/Year: |
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| QUESTIONS |
| What form of flea control do you use? |
Frontline
Advantage
Revolution
Revolution
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| What other pets are in your household? |
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| How does your dog interact with the other pets in your home? |
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| How does your dog act with children? |
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| How does your dog react with puppies? |
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| How does your dog react to dogs a great deal smaller than him/her? |
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| How does your dog react to dogs a great deal larger than him/her? |
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| Are there any types (i.e. large, furry) or breeds of dog that your dog fears of dislikes? |
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| Do visitors ever bring their dogs to your home? If yes, how does your dog react? |
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| Has your dog ever growled or otherwise acted in a menacing manner toward anyone approaching your, your home, yard, or car? If yes, please explain. |
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| Are there any kinds of people your dog tends to dislike (i.e. gender, personality type, etc.) If yes, please explain. |
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| Has your dog ever bitten someone? If yes, please explain |
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| Does your dog have any medical problem? If yes, what restrictions need to be place on your dog’s activities? |
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| Is your dog on any routine medications? If yes, what and how often? |
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| Have you ever tried to take food away from your dog? What happened? |
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| How does your dog respond if you or another dog takes away a toy that he/she is playing with? |
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| Does your dog ever play off-leash with other dogs? If so what types/breeds? |
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| Has your dog had any formal obedience training? If so, when and where? |
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| How do you correct and/or discipline your dog? |
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| Is there anything else we should know about your dog? |
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