1.  What is Your Name?

2.  What is your Address? Phone?


3.  What is your email?

4.  What is the name of your dog?


5.  Do you still own this dog?                     Yes    No

      If you do not still own this dog:
      a.  Did you sell him/her?                       Yes    No
      b.  Was he/she taken to a shelter?      Yes    No
      c.   Did he/she die?                               Yes    No
     If your dog died:  Please explain how and when?   

Health:
   
1.  Has your dog ever had problems with:

   Ears   
   Eyes   
  Skin     
  Joints    
  Heart     
  Thyroid
  Cancer
  Not listed

If you checked one of the above, please explain further and include any test diagnosis:


2.  What is your dogs weight?   

3. What is your dogs height?   
(measure from floor to center of back, between shoulders).

Temperment:

1.  Does/Did your dog show aggression/fear towards:
   People
   Other dogs
   Other animals
    Does noise bother him/her? Explain:


2. Has your dog attended formal training classes?
 Yes  No

If yes, to what level?
 

General:

1. What do you feed your dog?


2. How much exercise does your dog get?


3. Do you crate your dog? Under what circumstances?


4. What do you like most about your dog?


5. What do you like least about your dog?


Please e-mail or snail mail (CRM Danes, P.O. BX. 1461, Medina,TX.78055) a recent picture of your dog.  Thank you for taking the time to submit this form.
Mary Myers