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Family Information
Name 1
Profession
Name 2
Profession
Address
City
Zip Code
Email Address
Home Phone
Work Phone
Cell Phone
Emergency Contact
Emergency Contact Phone
Authorized person(s) who may pick up this dog
How did you hear about DogAmerica?
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Passerby
Website
Direct mail
Flyer
Friend
Veterinarian
Google
Word of mouth
Other
Other
Pet Information
Name
Birthdate
Breed
Color
Gender
Weight
Age obtained
How long have you had your dog?
Age when spayed/neutered
Veterinary Clinic
Veterinarian
Phone
What knowledge do you have of your dog’s past history prior to owning it?
How often does your dog play with other dogs?
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Rarely
Occasionally
Frequently
Often
Has your dog ever attended another Dog Day Care facility?
Yes
No
Has your dog attended a dog park?
Yes
No
If yes, how often?
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Rarely
Occasionally
Frequently
Are there any sensitive areas on your dog's body?
Yes
No
If yes, please explain
Does your dog have allergies?
Yes
No
If yes, please explain
Does your dog have any pre-existing or current medical conditions?
Yes
No
If yes, please explain
Why do you want your dog(s) to come to DogAmerica Day Center?
Crates
Is your dog crate trained?
Yes
No
What is your crate command?
What behavior is exhibited while in the crate?
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Is quiet
Whines
Digs
Barks
Protective
Toys and Games
Does your dog play with his/her toys
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Alone
With another pet
With human
Is your dog allowed toys at all times?
Yes
No
Behavior
When meeting another dog, your dog is (check all that apply):
Calm
Excitable/Happy
Shy/Nervous
Reluctant
Aggressive
Dominant
When meeting another person, your dog is (check all that apply):
Calm
Excitable/Happy
Shy/Nervous
Reluctant
Aggressive
Dominant
Does your dog have any separation anxiety?
Yes
No
If yes, please explain
Is your dog fearful of sounds?
Yes
No
Is your dog fearful of flashes of light?
Yes
No
If yes, what is the reaction to light flashes and/or particular sounds?
While at the veterinarian's office is your dog:
Relaxed
Nervous
Fearful
Muzzled
Other
Other
Are there any people your dog automatically fears or dislikes?
Yes
No
If yes, please explain
Are there any types of dogs your dog automatically fears or dislikes?
Yes
No
If yes, please explain
How does your dog react to another dog approaching in a park or on a walk?
On lead
Off lead
Describe your dog's usual play style (check all that apply):
Easy going
Likes games
Wrestles
Chases
Is vocal during play
Goes non-stop
Likes rough play
Is in charge
When your dog is upset for any reason, he/she:
Moves away
Hides
Is submissive
Barks
Shakes
Whimpers
Growly
Retaliates
Obedience
Has your dog had any basic obedience training?
Yes
No
Do you feel your dog is
Select one...
Well trained
Trained enough
Not trained at all
On a scale of 0-5, rate the following skills (5 = mastered)
Knows their name
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0
1
2
3
4
5
Sit
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0
1
2
3
4
5
Stay
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0
1
2
3
4
5
Wait
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0
1
2
3
4
5
Recall
Select one...
0
1
2
3
4
5
Additional information regarding your dog
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