Doggie Day Care Entry Questionnaire
Patients must be current on Physical Exam, Rabies, DHPP, Bordetella, Leptospirosis and Influenza vaccines in addition to an annual fecal/parasite exam and flea/tick prevention prior to their assessment.
Client Information:
Your Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient Information:
Pet's Name
*
Breed
*
Date of Birth/Pet's Age
*
Pet's Weight
*
Color
*
Sex
*
Please Select
Female
Female Spayed
Male
Male Neutered
Intact patients over 6 months of age are not eligible for doggy daycare
Vaccinations can be obtained from:
Clinic Name
*
Clinic Phone Number
*
Please enter a valid phone number.
Vaccination Records:
Browse Files
Drag and drop files here
Choose a file
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Patient History:
Does your dog like people?
*
Please Select
Yes
No
Does your dog get along with dogs?
*
Please Select
Yes
No
Does your dog have any chronic health conditions or injuries?
*
Please Select
Yes
No
Please specify.
*
Does your dog have any food or drug allergies?
*
Please Select
Yes
No
Please specify.
*
Is your dog on any chronic medications?
*
Please Select
Yes
No
Please specify.
*
Does your dog have any aggression related to food?
*
Please Select
Yes
No
Is your dog vocal?
*
Please Select
Yes
No
Does your dog have any aggression related to confined spaces or cages?
*
Please Select
Yes
No
Does your dog know basic commands such as: sit, stay, come, no?
*
Please Select
Yes
No
Is your dog easily aroused/excitable?
*
Please Select
Yes
No
Does your dog jump?
*
Please Select
Yes
No
Does your dog climb fences?
*
Please Select
Yes
No
Does your dog dig under fences?
*
Please Select
Yes
No
Does your dog ever participate in boarding?
*
Please Select
Yes
No
Does your dog experience stress diarrhea?
*
Please Select
Yes
No
Have any of the following every had an affect on your dog's behavior? Check all that apply.
*
Thunderstorms
Change in residence
Hot days
Vaccinations
Holidays
Vacations
Fireworks
Boardings
Large Crowds
Change in Weather
None of the Above
Which best describes your dog? Check all that apply.
*
High energy
Likes to hide & climb to high places
Wary of new friends
Keeps to him/herself
Uninterested most of the time
Always investigating
Particular about food/toys/bed
Loves naps
Easy going
Happy go lucky
Always worried
How many days a week do you think you would use doggy daycare?
*
Please Select
1-2 days
2-3 days
3-4 days
4-5 days
Once every couple of weeks
Which days a week would you want to use doggy daycare?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Signature
*
Date
*
/
Month
/
Day
Year
Date
Submit
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