New Client Questionnaire For multiple dog owners please complete one questionnaire for each dog.
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1 The Crate Escape, Too 5 Green Mountain Drive S. Burlington, VT DOGS (3647) The Crate Escape, Inc West Main St Richmond, VT New Client Questionnaire For multiple dog owners please complete one questionnaire for each dog. Owner s Name(s): Date: Mailing Address: City: State: Zip Code: HOME #: WORK #: CELL #: 2 nd WORK #: 2 nd CELL #: Weekday emergency contact information? Day: Eve: Weekend emergency contact information? Day: Eve: Address: Dog Name: Breed: Approx. Date of Birth: Sex: M / F Approx. Weight: Spayed or Neutered Y / N How did you hear about us? Ad in the newspaper The Burlington Free Press Seven Days The Other Paper Shelburne News Charlotte Citizen Other: Recommended by someone; name of person who recommended us Recommended by a Veterinarian, if so which one Radio Ad, if so which station Yellow Pages Internet: know our URL (website address) Internet: Search criteria (what you typed in to find us): Other Dog s General Information Age when spayed/neutered: Age when acquired? Where did you get your dog? Has your dog ever been to a daycare/boarding facility before? Yes, Name of Facility: 1
2 No If so, did the facility have: individual runs with no playtime with other dogs individual runs with some playtime with other dogs all day playtime with other dogs Was your dog comfortable at the daycare or boarding facility? Were you happy with the care they provided? If not, please explain: What is the main reason for bringing your dog to daycare? Temperament and Socialization Does your dog like to play with neutered males spayed females both intact males intact females To what types of social interaction has your dog been exposed? dog parks other daycare facilities dog classes dog friendly trails/areas neighborhood dogs play dates with friend s dogs Is your dog possessive of any toys, food, or objects? If yes, please explain: Has your dog ever growled or snapped at anyone taking food or toys away? If yes, please explain: Has your dog ever shared his/her food, toys, or bedding with other animals? yes no Has been destructive in the home? If so, please describe the damage done: What types of toys are your dogs favorite? How would you describe your dog s personality? Would you say your dog is more: dominant or submissive? What behaviors have you seen that may exhibit this? Are there any specific dogs to which your dog reacts negatively? neutered males spayed females intact males intact females smaller dogs larger dogs hyper dogs puppies specific breed: Has your dog ever bitten another dog? If yes, what were the circumstances under which that occurred? 2
3 Has your dog ever bitten a person? If yes, what were the circumstances under which that occurred? How does your dog react when approached by strangers at home or yard or out in public? How does your dog respond to other dogs while on a leashed walk? Training What is your dog s training history? (please check all that apply) No training Trained yourself Puppy Kindergarten Basic Obedience Intermediate Obedience Advanced Obedience Basic Agility Advanced Agility Private Sessions - work specifically on Other: *Please name the trainer or training facilities your dog has been to for the classes listed above? Medical / Behavioral Does your dog have any allergies? If so, please list: Are there any kinds of food or treats that your dog cannot have? What BRAND and type of food do you feed your dog? Does your dog have any medical problems or take any medications? If so, please explain: Does your dog have any physical problems or disabilities which may affect them when playing with other dogs? Does your dog need to be periodically rested during the day while at our facility? Does your dog have any kind of phobias/fears (i.e. thunder, loud sounds, vacuum, etc.) 3
4 Does your dog exhibit any problem barking behaviors? If so, what has been effective in quieting them down? While at home, does your dog follow you from room to room? How much exercise would you say your dog is getting? My dog (please check all that apply) Has jumped a fence? Height of fence? Has dug a hole under a fence & left the area? Eats his/her own feces? Eats other dogs feces? Mounts other dogs? Dumps over his/her water bowl? Plays in his/her water bowl? Is crate trained? Eats rocks? Destroys toys? Chews on his/her own collar? Che ws on other dog s collars? Is aggressive with other dogs Is afraid of water/hose? (Not sure) Has bitten another dog Has bitten a person Doesn t like to be left alone Has space issues in the presence of other dogs Is collar shy Has hip problems Jumps on people Has separation anxiety Is afraid of men Grooming Does your dog like to be brushed? Yes / No Are there any areas where your dog is sensitive to touch? Yes / No (ie. neck, ears, feet) If yes, what areas: How does your dog do with nail trims? 4
5 Does he or she need to be muzzled when having nails trimmed? Yes / No Is there anything else that you feel we should be informed of regarding your dog? 5
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