PALS Dog history

If you prefer a printable form please download the (pdf) or word document. Then mail or fax it to PALS. Thank you.

1. Date:

2. Owner/Handler:

First name
Last name
Phone #
Email

3. Dog's Bio:

Name
Date of birth
Breed of Dog
Weight of Dog

4. Gender:

Female
Female - Spayed
Male
Male - Neutered

5. Age of dog when acquired?

6. How did you acquire your dog?

7. If the dog was NOT a puppy, what do you know of its history?

8. Has dog attended obedience classes? Yes No

9. Highest Level achieved:

10. Which Commands will your dog obey?

a) Sit:	Usually	Sometimes	Rarely
b) Down:	Usually	Sometimes	Rarely
c) Heel:	Usually	Sometimes	Rarely
d) Come:	Usually	Sometimes	Rarely
e) Stay:	Usually	Sometimes	Rarely
f) Not Jump Up:	Usually	Sometimes	Rarely

11. What type of collar do you most commonly use?

12. Is dog used to walking on a leash? Yes No

13. Is dog fully house trained? Yes No

14. What is your dog's reaction to: (Check ALL that apply)

a) Other Dogs

b) Cats

c) Children

d) Vet's Office

15. Any other unusual reactions (i.e. men, uniforms, hats, people with canes)?

16. Has your dog ever growled, snapped at or bitten anyone?

Yes No

If yes, please provide detailed explanation:

17. Will your dog allow you to take food or other objects from its mouth?

Yes No

18. Which veterinary clinic do you use?

19. Currently rabies vaccinations are mandatory for all pets accepted into our program. Do you provide this protection for your dog?

Yes No, but I will, so that my application can be processed

20. Has your dog had surgery in the last 6 months?

Yes No

If yes, please provide details:

21. Is your dog on any medication?

Yes No

If yes, please provide details:

22. Has your dog ever been in a fight with another animal or had any experience which you may consider traumatic?

23. Might your dog be considered vocal?

Yes No

24. Will your dog be quiet on command?

Yes No

25. How does your dog fair riding in the car?

bad poor average fair good

26. List things your dog does NOT like:

27. Please detail any behavioral problems you have encountered with your dog:

Once you and your pet are accepted into the pet visitation program, you will be assigned to a team of volunteers visiting a specific facility on the SAME day or days of week each month. The following questions will help us find a suitable placement:

28. Do you and your pet have a strong preference for visiting:

Children Elderly No Preference

If you have a preference, please tell us why:

29. Which area of the city do you prefer?

NW SW NE SE No Preference

30. Days you are available: (No Pet Visits on Fridays)

Monday Tuesday Wednesday Thursday Saturday

31. Times you are available:

Morning Afternoon Evenings

32. Is there any day/time you are absolutely NOT available?

33. Is there any additional information you would like to add?