Registered Name:____________________________Call Name:________________

Sire:______________________________Dam:_______________________________

Birthdate:___________________Breeder:_________________________________

Sex:________Neutered:________Color & Markings:________________________
    (Attach photo-copy of registration or blue slip if available)

Date Acquired:____________________From Whom:__________________________

Address:__________________________Phone:______________________________

Shelter_______Placement_______Rescue_______Found________Other_________

Physical Condition: Height_______Weight____pounds (be exact as possible)

Coat Condition:___________________Apparent Injuries:__________________

Veterinary Evaluation:_______________________________________________*
    *attach written copy when available

Care Given: DHL [ ] Rabies [ ] Parvo [ ] Vet Exam [ ] Fecal [ ]
                 Vet Treatment [ ] Heartworm Exam [ ]

TEMPERAMENT: Reactions to: Food:____________________________________

Children:_______________________Adults (familiar)_____________________

Adults (strangers):_________________________Cars:_____________________

Shy?______________________Protective?________When?____________________

Where?___________________________Obedience Trained:___________________

Reaction to Discipline:_______________________________________________

Reaction to Other Dogs:_______________________________________________

Reaction to Other Animals:____________________________________________

Housebroken:______________Does he/she chew?________What?______________

Tendency to be destructive?________Of What?___________________________

Tendency to Chase?_____________What?__________________________________

What height fence does it take to confine this dog?___________________

Recommended type of placement (special conditions, use separate sheet if necessary)

__________________________________________________________________

__________________________________________________________________

Signature of Evaluator:_________________________________Date:_________