Survey - Pet Guardianship Questionnaire: Other Animal (Not Dog or Cat)

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Question - Required - Today's Date:

Month

Day

Year

YOUR INFORMATION

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Name:

Title	First Required	Last Required

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Email: Required

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Street 1: Required

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City/State/ZIP:

City Required	State Required	ZIP Required

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Mobile Phone: Required

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Question - Required - How many adults in the household?

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Question - Required - How many children in the household?

Question - Not Required - Please list ALL other pets residing in your home with whom THIS PET had contact. Include other pets' species/breed, age, gender, and whether they are spayed/neutered. Also include other pets' relationship with this pet:

YOUR PET'S INFORMATION

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Question - Required - Species / Breed of Pet (rat, bird/parakeet, hamster, reptile/bearded dragon, etc.):

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Question - Required - Pet's Name:

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Question - Required - Pet's Gender:

Male

Female

Question - Not Required - Please provide your pet's microchip number (if applicable):

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Question - Required - Pet's Age (approximately):

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Question - Required - How long have you owned this pet?

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Question - Required - Where did you acquire this pet?

Animal Control

Born at Home

Breeder

Friend / Family

Gift

Newspaper Ad

Pet Store

San Diego Humane Society

Shelter, Rescue, or Other Humane Agency

Stray / Found

Other

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Question - Required - How would you describe this pet, in general?

	Aggressive
	Calm
	Clingy
	Confident
	Cuddly
	Curious
	Dependent
	Excitable
	Fearful
	Friendly
	Happy
	Independent
	Nervous
	Outgoing
	Playful
	Shy
	Smart
	Stand-Offish
	Stubborn
	Submissive
	Vocal
	Other

BEHAVIOR INFORMATION

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Question - Required - How does this pet behave with ADULT members of the household? Select all that apply:

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal

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Question - Required - How does this pet behave with CHILD members of the household? Select all that apply:

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal
	Not Applicable

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Question - Required - How does this pet behave with ADULT visitors or strangers? Select all that apply:

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal

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Question - Required - How does this pet behave with CHILD visitors or strangers? Select all that apply:

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal

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Question - Required - Does this pet enjoy being held or handled?

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Question - Required - During an average day, how many hours TOTAL is this pet handled?

Never

1 - 2 hours

2 - 4 hours

4 - 8 hours

8 - 10 hours

10+ hours

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Question - Required - Has this pet ever bitten anyone?

Question - Not Required - If yes, please explain:

HOUSING AND FEEDING INFORMATION

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Question - Required - This pet is an:

Indoor Pet

Outdoor Pet

Indoor and Outdoor Pet

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Question - Required - How is this pet housed?

Aquarium

Cage

Free Access of Home

Free Access of Yard

Free Access of Home and Yard

Hutch

Other

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Question - Required - Was this pet housed with other pets?

Question - Not Required - If yes, please explain:

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Question - Required - In a 24-hour day, how long was this pet left alone at any given time?

less than 4 hours

4 - 8 hours

8 - 12 hours

12+ hours

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Question - Required - Is this pet a picky eater?

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Question - Required - What type / brand of food does this pet eat?

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Question - Required - How often do you feed this pet?

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Question - Required - What amount is fed per feeding?

Question - Not Required - List any of this pet's favorite treats:

Question - Not Required - List and explain any special needs this pet has or any special attention that this pet requires:

VETERINARY INFORMATION

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Question - Required - Vet's Name (first and last):

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Question - Required - Name of Vet Office / Practice:

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Question - Required - Vet's Phone Number:

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Question - Required - May we call your vet for information regarding this pet?

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Question - Required - Has this pet received notable veterinary treatment? This does NOT include regular check-ups and care:

Question - Not Required - If yes, please explain:

Question - Not Required - List and explain any medical issues / treatments / care that we should know about: