Duke Canine Cognition Center - Dog Registration Questionnaire
Please take a moment to fill out this questionnaire so that we can come to know your dog and can best place him/her in appropriate experiments (all experiments involve fun problem solving games that your dog will enjoy!).  The questionnaire should take 10 - 15 minutes and it's important that you fill it out as completely as possible (and please fill out one form per dog).  Please note the Center is located in Durham, NC and all testing takes place on site.  If fields marked with an asterisk are not complete we will not be able to enroll your dog in the DCCC.  It is important to remember that you can withdraw your dog from the experiments at anytime and that the submission of this form does not obligate you to participate in any way nor does it guarantee your dog's placement in our database.  Experiments are run in the DCCC year round, so although you may not be contacted about a study right away, please be patient!
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Owner Name *
Title
Address *
Please include full mailing address (including State & Zip)
Daytime Phone Number *
xxx-xxx-xxxx
Primary Email Address *
*Note: Email will only be used to contact you about your dog and possible testing opportunities.  Please be sure to use an email address that you will have continued access to (i.e. do not use your university email address if you will wish to remain contactable after it expires)
Can we occasionally (~2/year) invite you to participate in a survey via email? *
When are you and your dog primarily available? *
Check all that apply.
Required
Veterinarian's Name *
Veterinarian's Phone Number *
xxx-xxx-xxxx
Dog's Name *
Dog's Birthday (mm/yyyy) *
If unknown, please approximate.
Dog's Sex *
Is your dog spayed/neutered?
Clear selection
If so, at what age was the procedure done?
What is the approximate weight of your dog (in lbs)?
Is your dog a purebred? *
If so, what breed?
Is your dog registered with the American Kennel Club (AKC)?
Clear selection
Is your dog a mixed breed? *
If so, what breeds?
(Best Guess)
Date of your dog's last Rabies vaccine (mm/yyyy) *
An up-to-date vaccine is required to participate.
Date of your dog's last Distemper/Parvo/(Corona) vaccine? (mm/yyyy) *
This is often a combination vaccine with or without lepto.  An up-to-date vaccine is required to participate.
Date of your dog's last negative fecal result or broad sprectrum deworming? (mm/yyyy)
While not required, this is strongly recommended for participation.
Date of your dog's last Bordatella vaccine? (mm/yyyy)
While not required, it is strongly recommended that your dog has received this vaccine in the last six months.
Does your dog have any medical conditions we need to be aware of? *
If yes, please explain.
Does your dog have any dietary restrictions? *
If yes, please explain.
Does your dog have a history of aggression? *
Has your dog ever injured (eg. bitten) another dog? *
If yes, please explain.
Has your dog ever injured (eg. bitten) a person? *
If yes, please explain.
Does your dog ever exhibit any fear, anxiety, or aggression around men? *
This is very important, as we very often have male handlers and experimenters!
If yes, please explain.
Were you the dog's first owner?
Clear selection
How old was your dog at adoption?
Where did you get your dog?
Other
Has your dog ever taken any obedience/agility/training classes?
Clear selection
If yes, please list.
Can your dog accurately and obediently follow these commands? *
Yes
Mostly
No
Sit
Stay
Come
Go
How much contact does your dog have with humans?
Very little contact
Constant contact
Clear selection
Are there multiple dogs in the household?
Clear selection
If so, how many dogs total in the household?
When interacting with other dogs, is your dog...
Clear selection
Is your dog motivated by treats/food?
Clear selection
Does your dog have any special abilities?
Clear selection
If yes, please explain.
Does your dog ever do anything that surprises you?
Clear selection
If yes, please explain.
How did you hear about the Duke Canine Cognition Center?
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