Puppy / Kitten Questionnaire Owner’s Name: Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home NumberCell NumberWork NumberWhich of the above numbers do you prefer as primary contact number? Email Emergency Contact (other than immediate family): Phone NumberPet’s Name: Breed: Colour: Sex: Age: Birthday: MM slash DD slash YYYY PLEASE BRING A FECAL SAMPLE TO YOUR APPOINTMENTWhat date did you obtain your pet? MM slash DD slash YYYY How old was your puppy/kitten when you obtained him/her? Where did you obtain your pet? (private home, pet store, breeder, shelter or humane society, rescue group, other)? What veterinary care has your pet received so far? Please bring documentation if you have it. Vaccinations: Dates Given: Deworming: Dates Given: Name of deworming medications, if known: What diet are you currently feeding your pet?Dry kibble:Canned food:Treats: Add RemoveIf you know what diet your pet was fed prior to adopting him/her, please note it here. How often is he/she fed? Is food available all the time or at set "mealtimes"? Where does your puppy/kitten spend most of his/her day? (inside,outside, in a room, in a kennel, with you)? Do you have other pets? Yes No Are they in contact with the puppy/kitten? Are the other pets currently vaccinated? Yes No Not Applicable Are they currently on heartworm and flea/tick preventive medications? Are there any specific health issues you wish to discuss? Yes No Are there any other issues you wish to discuss? For Dogs:How would you describe your puppy's house training? Great, not having any accidents Good, a few accidents still but most of the time controlled So-so, having several accidents a day Not a clue, most elimination is happening in a location I do not prefer Comments:Is your puppy being house trained to go Outdoors only Pee pads or mats inside as well as outdoors Indoors only How is your dog kept when you leave him/her alone? Free in house behind a gate or door in house crate (location in house?) Where do you plan to exercise your dog? Dog parks –off leash local neighborhood walks/parks home property indoors only Do you expect to be taking your dog to grooming facilities boarding kennels obedience schools seniors homes or hospital visits USA or other countries Will your dog travel with you to vacation locations (cottages, etc). If so, where? (what geographic location specifically?) Have your enrolled your puppy in a puppy socialization class? Yes No If so,where? Have you seen any fleas or ticks on your puppy? Yes No For Cats:Have you seen any fleas or ticks on your puppy? Yes No If yes, do you expect your cat will be…? On leash In enclosed location (crate, ‘catio’, pen) free to roam Where is the litter box located? What type of litter are you currently using? Clumping litter paper pellets silica based crystals corn/wheat/nut shell litter non clumping clay litter Is the litter scented or unscented? Is the kitten using the box consistently (without ‘accidents’)? Yes No
