Dog Participation Questionnaire
Dog's Info
Dog's name: *
Your answer
Breed: *
Your answer
Age: *
Your answer
Weight: *
Your answer
Is your dog's weight 15lbs or less? *
DOB:
Your answer
Sex: *
Spay/Neuter *
How long have you owned your dog? *
Your answer
Did you acquire your dog from a Breeder? Shelter? Rescue? Prior Owner? As a stray? *
Your answer
Contact Information
Owner's name: *
Your answer
Street address: *
Your answer
City, State, Zip *
Your answer
Home phone:
Your answer
Cell phone: *
Your answer
Email: *
Your answer
Veterinarian:
Your answer
Veterinarian phone number:
Your answer
Medical & Behavioral History
Does your dog have any medical problems? *
Is your dog currently taking any medication? *
Has your dog ever taken medications or been treated for behavioral problems? *
Does your dog have special dietary needs or allergies to certain foods? *
Has your dog ever had a seizure or loss of consciousness? *
Has your dog ever had a head injury? *
Has your dog ever had surgery (besides spay/neuter)? *
Does your dog have any metal in the body other than a microchip? *
If “yes” to any above, please provide details here:
Your answer
Is your dog friendly with other dogs? *
Is your dog friendly with strange adults? *
Is your dog afraid of loud noises (e.g. thunder)? *
Is your dog afraid of new places? *
Do you think that your dog can learn to wear ear muffs or ear plugs? *
Is your dog fully housebroken? *
Is your dog microchipped? (microchips are MRI safe) *
Has your dog ever exhibited aggression toward family members? *
Has your dog ever exhibited aggressive behavior toward persons outside the family? *
Has your dog ever exhibited aggression toward animals within the family? *
Has your dog ever exhibited aggression toward non-family dogs? *
Has your dog ever exhibited aggression toward non-family cats or wildlife? *
If you answered "yes" to any of the agression questions, please categorize the type of aggression and then describe the event(s). Who was present (human and animal)? Why did the event occur- what transpired that in your opinion prompted the aggression? Was your dog on or off-leash? When did the incident occur (month-year, time of day, day of week)? Where did the incident occur (outside of home, home, room of house, provide details)? Did your dog only posture or did your dog actually make oral contact with the victim? How did the incident end (dog only postured, dog bit and then stopped, somebody intervened, other, provide details)? Were there any injuries (if yes, describe the injuries, their location, their severity, and whether they required medical treatment)?
Your answer
List other animals in the household (species, age, sex):
Your answer
List other people in the household (age, gender):
Your answer
Time Commitment
MRI training may take 2 to 4 months before your dog completes their first scan, after which they may participate in several studies. Are you available for the time commitment required to train your dog to participate? *
Homework: Dogs need 10 minutes per day to learn the "sit stay" required to stay still in their MRI chin rest. Do you have 10 minutes per day to work with your dog? *
How did you hear about participating in our studies? *
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