Why are you surrendering the pet?(required)
Dog's Name (required)
Nickname (required)
Age or Approximate Age (required)
Is the dog (required) —Please choose an option—MaleFemaleUnsure
Has the dog been spayed or neutered? (required) —Please choose an option—YesNoUnsure
Does the dog have a microchip? (required) —Please choose an option—YesNoUnsure
Has the dog ever been declared dangerous by any animal control agency or municipality? (required) —Please choose an option—YesNo
Where did you acquire the dog? (required) —Please choose an option—CCHSShelter or RescueFound as strayFriend/RelativePet StoreBreederNewspaper/Internet AdBorn in home/on propertyOther (enter below)
Other
If you have obtained this animal from another shelter, breeder, rescue group, or pet store, please provide the name and location of the source
What kind of food? (required) —Please choose an option—DrySoftBoth
What brand of food does your dog eat? (required)
What is the dog's feeding schedule? (required)
What treats does your dog like? (required)
Does your dog have chew bones? (required) —Please choose an option—YesNo
If yes, what kind?
Have you taken this dog to the veterinarian? (required) —Please choose an option—YesNo
If yes, Name of veterinarian?
If yes, Date of last visit?
Is dog current on his/her vaccines (Rabies, Distemper Combo)? (required) —Please choose an option—YesNoUnsure
Does the dog have any medical issues? (required) —Please choose an option—YesNoUnsure
If yes, please explain
Is the dog on any medications? (required) —Please choose an option—YesNo
If yes, please list medications
Please check all conditions that your dog has been diagnosed with or has been treated for (required) AllergiesUrinary Tract InfectionEpilepsy/SeizureDiabetesThyroid DiseaseSkin ProblemsRingwormHeart MurmurHeartwormOrgan FailureOtherNone of the above
How does the dog behave at the vet's office? (required)
What is your dog's best quality? (required)
What is your dog's worst quality? (required)
Describe in your own words the personality of your dog (required)
Traits that describe this dog's personality (check all that apply) (required) EnergeticShyPlayfulLap DogFriendlyAloofIndependentFearfulEasygoingStubbornAggressiveAffectionate
What is your dog's favorite style of play? (check all that apply) (required) GentleFetchHide and SeekDoes not show much interest in playingLoves toysWill learn tricks for treatsTugRoughPlaying with other dogsOther
What is your dog's favorite game or toy? (required)
How is your dog with their toys, food, and chew bones? (required)
Does your dog display any fear of (Check all that apply) (required) Loud NoisesThunderstormsFireworksOther
Are there other dogs in the house? (required) —Please choose an option—YesNo
If yes, How many?
If yes, please list each dog's age, size, sex, and whether they are spayed or neutered:
Describe how this dog behaves around other dogs in the home (check all that apply) No other dogs in the homeFriendlyAvoids other dogsPlayfulCoexists peacefullyFearfulAggressivePossessive of foodPossessive of non-food items
Describe how this dog behaves with small animals outside of the home like a cat or a squirrel (required)
The dog consistently responds to the following cues (check all that apply) (required) SitStayComeDownHeelFearfulShakeFetch
Do you use hand signals or a language other than English to cue this dog to perform certain behaviors? (required) —Please choose an option—YesNo
Is there anything else we should know about your dog's behavior? Please explain
Does this dog have any of the following behaviors you consider a problem? (Check all that apply) (required) Barks too muchJumps fencesRuns awayChews up household itemsChews up plantsNot housebrokenMarks territoryDestroys outside structuresDiggingPlays too roughGrowls or bitesSteals food/trashGuards toysGuards foodToo needyJumps on peopleLacks impulse controlSensitive to handlingDoor dashingMounts people or animalsUnpredictable aggressionKills other animalsChases runnersChases bicyclesChases carsChases wildlifeAggressive with strangersAggressive with animalsAggressive with childrenAggressove with adult ownersFearfulNone of these
If fearful, please explain
Has this dog ever been aggressive towards people or animals? (Check all that apply) (required) Yes-has bit peopleYes-has growled at peopleYes-has lunged at peopleYes-has bit a catYes-has growled at catsYes-has lunged at catsYes-has bit dogsYes-has growled at dogsYes-has lunged at dogsNo-has shown no aggression towards people or other animals
Please explain behavior/aggression in detail on what happened. We want to understand the behavior of what happened before, during and after. Type in "none" if this does not apply (required)
Was the dog: (required) —Please choose an option—Indoors except to pottyOutside 24 HoursOutdoors during the day and in at nightIn and out throughout the day
How often does this dog urinate or defecate in an inappropriate place? (Check all that apply) (required) NeverAccidents EverydayOccasionally has accidentsAccidents are feces onlyAccidents are urine onlyAccidents are urine and fecesAccidents when left alone for too longAccidents when company is overAccidents when meeting strangers
How does the dog behave in the car? (required)
Have you ever had any problems keeping the dog confined? (check all that apply) (required) No-stays in yardYes-jumps fenceYes-digs to get out
Was dog ever crated? (required) —Please choose an option—YesNo
No, if no; where
Yes, when left alone, how many hours?
How does this dog behave in a crate? (check all that apply) Calm-SleepsWhines-BarksAnxious at first-then calms downMoves crateHas accidents in crateTries to escape from crateDamages items in reachDroolsCannot be crated
If the dog cannot be crated, why?
What kind of excercise did this dog receive? (check all that apply) (required) Daily walk on leadWalked 1-3 times per week on leashPut out in fenced yardTaken off leash in park/countryPlaced on cable run outsideNo regular exercisePlayed with peoplePlayed with other dogsPlayed with catsOther
What kind of collar do you use (check all that apply) (required) Buckle collarBody harnessHead HalterMartingaleClip collar
How does the dog walk on leash? (required)
Has the dog been around children? (required) —Please choose an option—YesNoUnsure
If yes, please indicate the age range of children (check all that apply) 0-2 years old3-5 years old6-10 years old11-18 years old
How does this dog behave around children (check all that apply) FriendlyPlayfulCalmAvoids childrenIndifferentFearful
How does the dog act around women? (check all that apply) (required) FriendlyPlayfulCalmAvoids womenIndifferentFearful
How does the dog act around men? (check all that apply) (required) FriendlyPlayfulCalmAvoids menIndifferentFearful
Describe how this dog acts when people come to visit (check all that apply) (required) QuietExcited/FriendlyJumps on themBarks at doorbell or knock on doorFearfulAggressivePlay bitesBarks at people once insidePesters for attentionProtective of familyStarts out unsure - but warms up
Does the dog have any sensitive places? (required) —Please choose an option—YesNoUnsure
If yes, where, and how does the dog react?
Please add additional information/comments that would be helpful to the CCHS staff (required)
Your Name (first and last) (required)
Your Phone Number (required)
Your Email Address (required)
Your full address (required)
Today's Date (required)
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