Dog Owner Questionnaire

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1 Dog Owner Questionnaire 2070 Griffin Road Fort Lauderdale, FL Dogs can t talk, so they can t tell us where or whom they would like to live. To ensure that their home is a safe, happy and appropriate place for your dog to live, we need you to fill out this form in as much detail as possible. Detail and honest information from you is crucial to our placement process, so please take the time to fill in this profile with care and accuracy. Undesirable behaviors and medical issues do not necessarily create problems in placement, however, not disclosing those problems definitely does. Dishonest or incomplete responses can undermine the safety and happiness of both your dog and the new adopting family. If there are any questions that are unclear or that you are uncomfortable responding to for any reason, please ask to speak directly to one of our helpful staff members about the issue. Owner s Name Address City State Zip County Phone number Alternate Phone number address How did you hear about the Humane Society of Broward County s Surrender by Appointment Services? GENERAL ANIMAL INFORMATION ANIMAL ID (for clinic use only) (check the correct answer when applicable) Dog s Name: Dog s age or approximate age: Breed of Dog: Dog s Sex: Male Female Unsure 1. Is your dog spayed/neutered? Yes No Unsure

2 2. What kind of I.D. does your dog have (tattoo or microchip)? Tattoo (If so, where is it located) Microchip # 3. Is this I.D. registered in your name? Yes No If no, who is the I.D. registered to? HISTORY 1. Why are you surrendering your dog? 2. If surrender reason is behavioral, please explain: 3. If we could help you resolve this issue would you be interested in keeping the dog? 4. Have you tried to find a home for this dog on your own? Yes No If yes, how did you go about this? 5. Have you contacted breed-specific rescue groups for help in re-homing your dog? Yes No 6. How long have you owned your dog? 7. Including yours, how many homes has your dog had? 8. Where did you acquire this dog?(check best answer) From Humane Society of Broward Another shelter Breeder Found as a stray Newspaper/Internet Ad Friend/relative Pet Store Born in my home Other LIFESTYLE AND HOME LIFE 1. Has this dog lived with other dogs? If yes, how did they interact? 2. How is your dog s behavior around dogs it is not familiar with? (check all that apply) Aggressive with all dogs Bossy Frightened Ignores or is indifferent Gentle/Submissive Roughhouses Aggressive with

3 same sex dogs Other: 3. Would you recommend placing this dog in a home with other dogs? Yes No If no, please explain: 4. Has this dog lived with cats? Yes No If yes, how did they interact? 5. Did the dog need supervision with the cat at first? Yes No 6. How does the dog react to cats outside of its home that are unfamiliar? 7. Would you recommend placing this dog in a home with cats? Yes No If no, please explain: 8. Where did the dog live when no one was home? (check all that apply) Free run of the house Crated In fenced yard In garage or basement Confined to kitchen/bathroom Outside on chain or runner Screened in patio Electronic pet containment Other: 9. If the dog is crate trained, how many hours did it spend in the crate each day? 10. Has your dog ever been kenneled at a: (check all that apply) Private boarding facility Veterinarian Animal Shelter If yes, how did your dog react to being boarded? 11. Where does your dog sleep at night? 12. Has your dog lived with or been around children? Yes No If yes, what were the children s ages and how did they interact?

4 MANNERS AND TRAINING 1. Is this dog housetrained? Yes No Almost (started training) If no, please explain: 2. Can the dog be allowed off-leash and come when called? Yes No 3. Can this dog be left alone in the house for 8 hours a day without issues? Yes No If no, why not? 4. Is the dog destructive if left alone inside the home? Yes No If yes, please explain: 5. Please tell us about the desirable tricks and habits you have taught your dog to do: (check all that apply) Basic obedience commands Rides nicely in the car Come when called Play fetch Walk on a loose leash Greets visitors politely Shake/paw trick Takes treats gently Waits for food Get on & off furniture when asked Other: 6. What words does your dog understand? (check all that apply) Sit Stay Down Heel Come Leave it Drop Wait Off Fetch Doesn t know any commands Other: 7. How does the dog react in a car? 8. How does the dog behave on a leash? 9. When the dog is on leash and sees a strange dog or cat, what is its reaction? 10. Is the dog protective or possessive of any of its toys, treats or food? Yes No If yes, please explain: 11. Are there any wonderful or special traits/habits that you would like his/her new family to know about?

5 MEDICAL HISTORY 1. Did the dog see a veterinarian on a regular basis (at least once a year)? Yes No 2. May we contact your veterinarian? Yes No If yes, what is the veterinarian s name and number? 3. Is the dog current on annual vaccinations? Yes No 4. How does this dog react when at the vet? (check all that apply) Calm Nervous Needs to be muzzled Happy/friendly 5. Has this dog ever been hit by a car or required surgery/hospitalization? Yes No If so, please explain: 6. Has this dog ever been diagnosed or treated for any of the following conditions by a veterinarian? (check all that apply) Hair loss Diarrhea Sneezing Coughing Runny eyes Worms in stool Vomiting Other illness/condition: 7. Did a veterinarian diagnose or treat the condition(s)? Yes No 8. Does your dog require any medication on a regular basis? Yes No If yes, explain type of medication and illness: 9. Does the dog allow you to clip his/her nails? Yes No 10. Does the dog liked to be brushed? Yes No 11. Are there places on the dog s body he/she does not like being touched/ brushed/petted? Yes No If yes, please explain: 12. Has your dog ever been professionally groomed? Yes No If yes, how did the dog behave?

6 DIET, EXERCISE, AND PLAY 1. What brand of food do you feed? 2. How often do you feed? 3. Do you feed: Wet food Dry food Combination of wet and dry 4. Does your dog have any allergies or sensitivities to any grains or common food ingredients? Yes No If yes, which grains or ingredients? 5. Describe your dog s play style with other dogs: Please tell us any additional comments about your dog that would be helpful to families considering adopting him/her:

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