Pug Intake Evaluation

Pug Name:

Pug ID Number:

Date of Surrender:

Supervising Board Member:

Signalment

Gender:

Male
Female

Altered?

Yes
No

Age:

Color:

Distinguishing Characteristics (if any):

Date of Last:

Vet Visit:

Rabies Vaccination:

Distemper Vaccination:

Kennel Cough Vaccination:

Lyme Vaccination:

Has pug been taking flea/tick preventatives?

Yes
No

Has pug been taking heartworm preventatives?

Yes
No

Current Medications:

Outstanding Medical Conditions:

Additional Vet Record Comments:

Eyes:

Ears:

Nose & Nares:

Mouth & Teeth:

Fleas:

Skin:

Coat:

Nails:

Anus/Anul Glands:

Urine:

Stool:

Housebroken?

Posture & Gait:

Estimated Weight:

Eating & Drinking Habits:

Body Condition:

Hydration:

Mentation:

Current Food Brand:

Temperature:

Heart Rate:

Respiration Rate:

CRT (Capillary Refill Time):

Is pug marking?

Yes
No
Particular area(s) of the home

Is pug dog aggressive?

Is pug cat or other small animal agressive?

Yes
No

Is pug good with children?

Is pug aggressive with adults?

Yes
No

Does pug food or resource guard?

Yes
No

Is pug crate trained?

Yes
No

Does pug bark excessively?

Yes
No

Energy Level:

Low
Moderate
High

Does pug walk well on leash?

Other Behavioral Concerns:

Any other comments or clarifications:

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