Client Intake Questionnaire
Please answer the following questions that follow as thoroughly as possible. All answers are confidential and will help us to serve you better.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Dog's Name
Breed
Weight (lbs)
Age
Male
Intact
Female
Spayed / Neutered
If spayed/ neutered, at what age?
Fenced Yard?
How did you hear about us?
Veterinarian
Former Client
Internet
Rescue/Shelter
Other
Where did you obtain your dog?
Breeder
Individual
Shelter/ Rescue
Pet Store
Friend/ Relative
Found Stray
Other
How long have you had your dog?
Why did you get your dog? Please check all that apply.
Companionship
For the kids
For protection
To breed
Received as a gift
Sports/work
Assistance/ Service / Therapy Dog
Companion for other dog
Other
Is this your first dog?
Yes
No
List any physical/ breed characteristics that contributed to your choice for your dog:
What Veterinarian do you use?
Is your dog up to date on vaccinations?
Yes
No
Any Medical Problems or Allergies?
Yes
No
If yes, please describe allergies or medical issues:
Is your dog easily handled by vet staff?
Yes
No
If no, please describe behavior.
How much exercise / outside time does your dog get per day?
Where is your dog kept when you are not home?
Where does your dog sleep at night?
How many hours is your dog home alone per day?
Any other pets in home?
What are 3 things you like about your dog?
What are 3 things you dislike about your dog?
What commands or cues does your dog know?
Check the behaviors that apply to your dog:
Aggressive (describe below)
Jumps on people
Mouthing/ Nipping
Urinates in house
Steals food/objects
Guards food/toys/bones/other
Excessive vocalization
Threatening/ biting family or friends
Fearful (describe below)
Pulls on leash
Chews furniture/property
Urinates when excited
Darts out doors/gates
Excessive attention-seeking
Threatening/ biting strangers
Anxious when alone
Destructive when alone
Digs in yard
Defecates in house
Escapes from yard
Jumps on furniture
Does not understand commands
Threatening/ growling at other animals
Other (describe below)
Describe Below...
What would you like help with, in order of importance?
Has dog ever bitten another a person or animal?
Yes
No
What is your dog's usual reaction when a person they have not met before enters your home?
Is there anything else you feel it would be important for us to know?
Thank you for taking the time to complete this form. Your answers will allow us to serve you better.
WE LOOK FORWARD TO MEETING YOU AND YOUR DOG!
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