Heart of Ankeny Animal Hospital

701 Ordnance Rd.
Ankeny, IA 50023

(515)635-0095

www.heartofankeny.com

Daycare Questionaire

Thank you for choosing Heart of Ankeny for your dog's care!
We strive to provide the best quality service including a healthy, calm, fun, and sanitary atmosphere! Therefore, we require our new daycare clients to fill out the following information to help us gain some knowledge about your dog(s). If you are registering more than one dog, please fill a form out for each individual dog.
Owner Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Name of Dog: (required)

Gender: (required)

Male
Female


Age of Dog: (required)

Breed: (required)

How long have you owned your dog? (required)

Altered? (required)
(* All pets over 6 months of age are required to be spayed or neutered in order to participate in daycare.)

Yes
No


Medical History
Does your dog have any past or current medical issues or injuries we need to be aware of? (required)

Yes
No


If yes, please explain.

Is your dog current on age appropriate vaccinations? (required)
(* To attend daycare your dog must be current on Rabies, DAPP, and Bordetella vaccines.)

Yes
No


If you are not a veterinary patient of Heart of Ankeny please list your veterinarian. (required)

Is your dog current on flea/tick and heartworm prevention? (required)
(*to attend daycare it is required that your dog is current on flea/tick prevention.)

Yes
No


If yes, please list what products you are currently using.

Does your dog have any allergies or dietary restrictions? (required)

Yes
No


If yes, please explain.

Training History
Has your dog attended any training or obedience classes? (required)

Yes
No


If yes, please list classes/training attended below.

What commands does your dog know and respond to? (required)

Do you use and electronic fence or bark collar for your dog? (required)

Yes
No


If yes, please explain.

Social History
Describe your dog's energy level. (required)

Low
Medium
High


Has your dog ever bitten or been aggressive with a person? (i.e. groomer, vet, strangers) (required)

Yes
No


If yes, please explain.

Has your dog ever shown aggressive behavior towards another dog? (required)

Yes
No


If yes, please explain.

Has your dog ever been in a situation with another dog that resulted in a bite wound to either dog? (required)

Yes
No


If yes, please explain.

Does your dog have issues with loud noises or thunderstorms? (required)

Yes
No


Does your dog exhibit destructive behavior when left alone? (required)

Yes
No


Does your dog willingly accept handling by others? (i.e. grooming, nail trims, etc.) (required)

Yes
No


Is there anything your dog is scared of? Please list below and explain how you handle it (required)

Please list some of your dog's favorite activities. (required)

Has your dog ever jumped a fence or gate higher than 4 feet? (required)
(If yes, please list training completed.)

Yes
No


Does (or has) your dog shown signs of resource guarding? (toys, objects, people, etc.) (required)

Yes
No


If yes, please explain.

Has your dog been to an off leash park? (required)

Yes
No


Does your dog get along with other dogs or ever play in a group setting? (required)

Yes
No


Does your dog recall well? (required)

Yes
No


Does your dog ever bark excessively? (required)

Yes
No


Why do you want to bring your dog to play time? (required)


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