Dog Lifestyle Assessment Form

Owner's Name: *

Email Address: *

Phone Number: *

Dog's Name: *

Age: *

Sex: *

Breed: *

Color: *

If more than one pet:

# of cats

# of dogs

Other:

Microchip number (if known):

Help us learn more about your dog by checking all of the following that apply:

My dog goes for long walks with me in the neighborhood.My dog is friendly and loves to interact with other dogs when we walk.My dog is afraid of other dogs and will not go near them.

My dog attends:

ShowsField TrialsDay careObedience Classes

My dog goes to the park and plays with other dogs.Friends bring their pets when visiting my home.My dog has been known to bite or snap.My dog stays in the backyard at all times.My dog is indoors most of the time and only goes outside in the backyard.My dog goes for a run by himself in the neighborhood daily.

I remove ticks from my dog:

DailyWeeklyMonthlyNever

My dog visits or lives on a farm or other rural facility.My dog goes to the groomer.A groomer comes to my premises to groom my dog.I volunteer/work at an animal shelter/rescue facility/wildlife center.My dog was purchased from a pet store.

If yes, store name:

My dog was purchased from the humane society.My dog was adopted from a private household (not a breeder).My dog was a stray.My dog was purchased from a breeder.

If yes, registered name:

My dog boards when we go on vacation.My dog travels with me with we go on vacation.A pet sitter comes to my house when we go away on vacation.

My dog is afraid of:

Cats:Other Dogs:People:My dog is afraid to visit the veterinary hospital.I or someone in my family experiences chemotherapy, diabetes, or another immune suppressive disease/disorder.

How important is your pet's health to you?

How important is it to you that your pet is not in pain?

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Help us learn more about your dog by checking all of the following that apply:

My dog attends:

I remove ticks from my dog:

My dog is afraid of: