Questionnaire   Date _______________ Dog's name _______________________ Age _____Sex______Breed ____________________ Is he/she spayed/neutered? Y / N____________________   Owner's name, address, phone number ____________________________________________ ____________________________________________________________________________ Names and numbers we can call for an emergency ____________________________________ ____________________________________________________________________________ What is the name and phone number of your dogs vet? ________________________________ ____________________________________________________________________________ What is your dogs favorite game or toys?____________________________________________ Would you like your dog to swim in our pond if appropriate? Y / N How does your dog act around other dogs - aggressive, skittish, confident, playful, etc. _______ ____________________________________________________________________________ Has your dog ever been around a large of number of dogs? Y / N If so, how did he/she react? ______________________________________________________ Has your dog ever been in a dogfight? Y / N Has your dog ever growled at or bit a person? Y / N How does your dog behave around small children? ____________________________________ Does your dog like to jump fences? Y / N Does your dog have arthritis, hip dysplasia or any other health problems? Y / N If so, please explain. ___________________________________________________________   Is your dog on any medications? Y / N Type? ________________________________________ If kenneling, is your dog on a special diet? Y / N If so, what kind? _____________________ If kenneling, how much do you feed your dog? _______________________________________ Any canned food? ___________________________________ If kenneling, has your dog been boarded before ? Y / N If so, how did they react? _____________________________   I, _______________________________________________, hereby claim that all the above (signature) information is correct and all inclusive regarding my dog's health and behavior history.
	Country Livin' Dog Daycare & Kennels LLC 30918 Peterson Rd. Philomath, OR (541) 929-3356 Send Email