Canine Surrender Profile

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1 Canine Surrender Profile Canine Profile The following questionnaire provides Elmbrook Humane Society (EBHS) with more information about your dog in order to learn more about his/her behavior. Because your dog is likely to behave in similar ways in his/her new home, this information helps us find the most suitable match for your dog. Your open and honest answers are necessary and appreciated. I certify that the information I am about to provide is accurate and truthful to the best of my knowledge. Owner Information Name Address Address (city, state, zip) Telephone Number Alternate Number

2 Date: Dog and Household Information: 1. Dog s Name 2. Sex Male Female 3. Age Years Months 4. Breed 5. How long have you had this dog? Years Months 6. Is the dog spayed or neutered? Yes 7. Where did you get this dog from? EBHS Friend/Relative Newspaper/Online Found/stray Breeder Pet Store Other shelter/rescue Other (please describe) 8. Why are you surrendering this dog? 9. Including yourself, how many people of the following ages live in your household? Age Range Female Male 0-3yrs 4-9yrs 10-17yrs 18-29yrs 30-59yrs 60+yrs 10. If you checked off children under the age of 10, is your dog tolerant/friendly toward the children? Yes (please explain) 11. What other animals did your dog live with? No other animals in the household Dogs Cats Other (please describe) 12. If you have other dogs, what are their breeds, ages and sexes? 13. If you have other pets in the household, did your dog get along with them? Yes (Please explain) Sometimes (Please explain)

3 Typical Behavior/Tendencies: 14. How does your dog usually behave toward the following? (Please check boxes) People your dog knows Men Women Children Unfamiliar People Men Women Children Animals your dog knows Dogs Cats Unfamiliar Animals Dogs Cats Never Encounter Friendly Afraid Shows teeth/growls Snaps Bites None Please explain the circumstance of the snap or bite (if applicable). If you checked more than one bite or snap above, please explain the circumstance of each. 15. Does your dog usually uncontrollably chase or attempt to chase any of the following? (Please check all that apply) Joggers Bicycles Skateboarders/Roller Bladders Cars/Motorcycles Outdoor cats Squirrels or other small animals Birds Doesn t chase Other 16. How does your dog usually react when you or another family member do the following to him/her? (Please check boxes) Bathe Brush Wipe Feet Hug Pick up Never Tried Enjoys Allows Afraid Shows teeth/growls Snaps Bites None

4 17. How does your dog usually react when an unfamiliar person approaches or enters the yard? Friendly Afraid Barks Shows teeth/growls Snaps Bites ne of these 18. How does your dog usually react when an unfamiliar person approaches or enters the house? Friendly Afraid Barks Shows teeth/growls Snaps Bites ne of these 19. Do you have a fenced in yard? Yes N o 20. When outside, does your dog stay on your property? Yes 21. Do you take your dog for walks? Yes If so, how often? 22. Does your dog walk well on leash? Yes 23. Does your dog act differently off leash vs on leash? Yes (please explain) 24. Does your dog usually have accidents in the house? Yes (specify how many times/day) 25. Is your dog crate trained? Yes If no, have you had issues crating? 26. Where does your dog spend most of his/her time? Inside the house, free roam Inside the house, crated Outside, free roam in the yard Outside, tied Other 27. How long is your dog left alone during the day? Zero 1-3 hours 4-8 hours 9-12 hours 12+ hours 28. When your dog is alone, he/she is Outside Inside (free roam) Inside (crated) Inside (confined to room) Other 29. When left alone, does your dog usually show any of the following behaviors? (Check all that apply) Destroy household items Urinate/defecate Bark Cry ne of these Other 30. When you are home, does your dog usually show any of the following behaviors? (Check all that apply) Destroy household items Urinate/defecate Bark Cry ne of these Other

5 31. When your dog plays, does he/she typically Jump Growl Bark Play bites ne of these Other 32. What toys does your dog like to play with? Balls Frisbee Plush Squeaky Tug Toy ne Other 33. What games does your dog like? Fetch Tug Chase Wrestling ne Other 34. What is your dog s favorite thing to do? 35. Is your dog afraid of anything? Yes (please describe) 36. What are your dog s bad habits? 37. Is your dog allowed on the furniture? Yes (describe what items) 38. Where does your dog usually sleep at night? Crate Floor Dog bed Couch Owner s bed Other 39. Does your dog receive bones, kongs, rawhides, pig ears or chewies? Yes If yes, what did your did you give your dog and how often? 40. Does your dog do any of the following while enjoying the bone or kong mentioned above? Growl Snap Show teeth Bite Other 41. What commands does your dog know? Sit Stay Down Come Heel Shake Other 42. Has your dog attended any obedience training classes? Yes (list when/where) 43. Does your dog enjoy car rides? Yes 44. What is your dog s best quality?

6 Dog Behavior/Aggression 45. Is there any report of your dog ever inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)? Yes Don t know If yes, please explain 46. Has your dog ever attacked another dog resulting in severe injury or death to another dog? Yes Don t know If yes, please explain 47. Has your dog ever attacked another domesticated animal species (cats, small animals etc)? Yes Don t know If yes, please explain Medical History 48. Does your dog see a veterinarian at least once a year? Yes 49. If yes please specify the veterinarian name and contact information: Veterinarian Name Contact Info 50. Is your dog current on his/her vaccines? Yes 51. If your dog has ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer please check all that apply. Examine (ears, teeth etc) Restrain Administer vaccines Trim Nails Draw Blood Shows teeth/growls Snaps Bites None 52. Does your dog have to be muzzled at the vet? Yes 53. Does your dog have any past or present medical conditions? Yes (please describe)

7 54. Is your dog currently on any medication or special diet? Yes (please describe) 55. What type of food does your dog eat? EBHS Representative (initials)

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