Client Intake Form - Your Pup Life

Name *

First

Last

Street Address *

City, State, Zip *

Home Phone

Cell Phone *

Email *

Preferred Contact *

Occupation

Dog's Name *

Dog's Gender *

Dog's Breed *

Dog's Birthday or Approx. Age *

Dog's Weight

Color

Does your dog have food allergies?(if yes, explain) *

What type of home do you live in? *

Fenced in Yard? *

Yes
No

Invisible Fence? *

Yes
No

Where did you obtain your dog? *

Rescue, Breeder, gift, etc

How long have you had your dog? *

Were there previous owners? *

Yes
No

If yes to above, please explain

Why did you get your dog? *

Companionship, for the kids, was a gift, for protection, etc.

Have you had dogs in the past? If yes, what kind? *

List any physical/breed characteristics that contributed to your choice for the current dog?

Any specific issues we should be aware of?

Veterinarian's Name: *

Veterinarian's Location: *

Month/Year of last visit *

Reason for last visit: *

Current Health Problems/Medications: *

Past medical conditions/treatments: *

Is your dog easily handled by vet staff? *

yes
no

Has your dog ever needed to be muzzled? *

yes
no

May we contact & discuss health & behavioral issues with your vet? *

yes
no

If yes, please initial:

What type of food do you feed your dog? (e.g. raw, dry kibble, canned, etc) *

How often? *

How much *

At approximately what times? *

Does your dog finish all food at meals? *

Yes
No
Sometimes

if not, how long is the food left down?

Does your dog receive other treats/chews?

Yes
No

Frequency/type:

Please list 3 of your dog's favorite foods/treats: *

Has your dog ever become possessive of his food or a treat? *

Yes
No

If yes, please describe:

Is your dog reliably house-trained? *

Yes
Mostly (infrequent accidents)
No

Is your dog crate trained? *

Yes
No

Do you have a dog door?

Yes
No

If not, how many times daily do you let your dog out (or take him/her on walks) to eliminate when you are at home?

How many times a day does your dog normally defecate?

What type of exercise does your dog get? (If not receiving any exercise at this time, note "none" and the reason.) *

How long does the exercise last/how often is is provided? (For example, "a 15-minute walk three times daily," or "plays with the neighbor's dog for an hour once a week.")

Who is normally responsible for exercising your dog?

If walks are provided, what type of collar and leash is being used? (Collar examples; regular buckle collar, halter head collar, bod harness, pinch/prong collar, choke chain. Leash examples; 6 foot lead, retractable leash)

Does your dog ever become reactive toward other dogs or people while on walks?

Yes
No

If yes, please explain:

List all people, including yourself who live in your household: Please include name, gender, age and relationship to you. *

Who will be responsible for practicing training exercises with the dog? *

Does your dog “belong to” a particular household member (e.g., son) or everyone? *

Do any household members dislike the dog, and if so, why?

Are any household members frightened of the dog, and if so, why?

Is the dog frightened of any household members, and if so, why?

Where is your dog kept when you are not at home?

When you are at home, is your dog allowed in the house?

Yes
No

If your dog is not allowed indoors at all, why not?

If your dog is an outdoor dog, would you like him to eventually be able to be indoors?

Yes
No
Maybe

If indoors, is your dog ever confined (crated, penned) while you are home?

If so, how long is your dog confined on an average day? And what are the reasons?

Where does your dog sleep at night?

How many hours per day is your pet without human companionship?

Do you have other pets?

Yes
No

If so, what kind, breed, age, sex, neutered?

If your other pet is a dog or cat, how does your dog get along with the other pet?

Does your dog play with toys or play games?

Yes
No
Sometimes

If so, what are his favorite toys/games? (These may be interac-tive games like tug or toys he/she plays with alone.)

What other activities does your dog enjoy?

Three things I like about my dog are:

Three things I do not like about my dog are:

Do you have any long term goals for your dog (i.e. therapy work, travel, going to restaurants, sporting events, etc)?

So far, what kind of training have you tried?

If group classes, did you complete the course?

Yes
No

Training methods used

Food treats
Praise
Verbal corrections
Physical corrections

List organization name and/or trainers name:

Please check the behaviors your dog knows and can do reliably (more than 90% of the time).

Check all the behaviors that apply to your dog:

Space to describe above:

List any procedures/training equipment you’ve used to try to correct the behaviors checked above:

What would you like help with, in order of importance?

Has your dog ever bitten anyone?(if so, describe)

Has your dog ever bitten another animal?(if so, describe)

Has. medical attention been necessary (for humans or animals) because of any aggressive incident? (if so, describe)

What is your dog’s usual reaction when a person he has not met before enters the home?

When was the last time a person unfamiliar to your dog entered the home?

Is there anything else you feel it would be important for us to know?

How did you hear about Pup Life?

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