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Intake Dog History Questionnaire
Email for non-humans
Dog Name
*
Age
*
Sex
*
Male
Female
Spayed/Neutered
*
Yes
No
Breed
*
Colour
*
In heat/Pregnant/Nursing
ID (Tattoo/Microchip)
Health Information
Does your dog have any past or present medical conditions
*
Yes
No
If yes, what are they
*
Current medications (please specify)
Current diet (please specify)
Do you give us permission to get your files from your vet
Yes
No
If yes, which veterinarian clinic do you use
*
Reason For Surrender
Moving (unable to bring dog)
Cost of having a pet
Pet is ill/injured
Aggressive
Too many animals
Unable to dedicate necessary time
Inappropriate elimination
Behaviour issue
Other
Behaviour issue (please specify)
*
Other (please specify)
*
History
How long have you owned your dog
*
Has your dog had other owners
*
Yes
No
If yes, do you know if this dog was previously kept indoors or outdoors
Is your family
*
Quiet live alone
Retired couple
Active family
Quiet family
Someone always home
No one home during day
Children
Other
Is your family Other
*
Is your dog
*
Accustomed to active children
Accustomed to calmer children
Nervous around children
Accustomed to being handled by children
Avoids children
Enjoys attention
Enjoys being picked up
Age of any children in house
Is your dog comfortable with
Women
Men
Children
Seniors
Loves all People
Does your dog get along with
All animals
Only dogs
Only Male dogs
Only Female dogs
Only cats
Does not get along with other animals
If does not get along with other animals, please explain (i.e. aggressive towards other animals, or ignores other animals)
*
Has your dog lived with other animals
*
Cats
Dogs
Other animals
Number of cats and gender
*
Length of time dog and cat(s) living together
*
Number of dogs and gender
*
Length of time dogs were living together
*
Other Animals
*
Diet
What do you feed your dog
*
Dry
Canned/wet
Both
Brand of food
*
Number of times per day your dog is fed
1
2
3
Free feed
What is the status of your dog’s appetite
Good
Fair
Poor
Fussy
Favourite treats
Food to avoid
Behaviour
How does your dog usually behave toward the following? Please check all that apply
People My Dog Knows
Men
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Women
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Children
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Unfamiliar People
Men
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Women
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Children
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Animals My Dog Knows
Dogs
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Cats
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Other Small Domestic Animals
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Unfamiliar Animals
Dogs
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Cats
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Other Small Domestic Animals
*
Never Encountered
Friendly
Afraid
Shows Teeth/Growls
Snaps
Bites
None of These
Does your dog chase or attempt to chase any of the following
*
None
Joggers
Cyclists
Skateboarders
Roller Bladers
Cars
Motorcycles
Squirrels
Outdoor cats
Children
Dogs
Other
Other
*
Does your dog play
*
Gentle
Somewhat rough
Very rough
Doesn’t play
When your dog plays, he/she
*
Jumps
Growls
Barks
Grabs clothing
Bites lightly
Bites hard
None of the above
Is your dog afraid of something(please describe)
How does your dog usually react when you or another person does the following? Please check all that apply
Hugging
*
Never Tried
Enjoys
Allows
Afraid
Soft Mouthing
Shows Teeth/Growls
Snaps
Bites
No Reaction
Bathing
*
Never Tried
Enjoys
Allows
Afraid
Soft Mouthing
Shows Teeth/Growls
Snaps
Bites
No Reaction
Brushing
*
Never Tried
Enjoys
Allows
Afraid
Soft Mouthing
Shows Teeth/Growls
Snaps
Bites
No Reaction
Wiping Feet
*
Never Tried
Enjoys
Allows
Afraid
Soft Mouthing
Shows Teeth/Growls
Snaps
Bites
No Reaction
Vet Visit
*
Never Tried
Enjoys
Allows
Afraid
Soft Mouthing
Shows Teeth/Growls
Snaps
Bites
No Reaction
Nail Trimming
*
Never Tried
Enjoys
Allows
Afraid
Soft Mouthing
Shows Teeth/Growls
Snaps
Bites
No Reaction
Groomer Visits
*
Never Tried
Enjoys
Allows
Afraid
Soft Mouthing
Shows Teeth/Growls
Snaps
Bites
No Reaction
Does your dog urinate/defecate outside
*
Yes
No
Paper trained
If yes, please specify how many times per day
Does your dog have “accidents” in the house
*
Yes
No
If yes, please specify how frequently
*
Daily
1-2 x/week
1-2x/month
If yes, is it
*
Urination
Defecation
Both
Is your dog is left alone, without people for (hours)
*
Never
1-3
4-8
9-12
Over 12
When alone, your dog is
*
Outdoors chained Outdoors in fenced area
Free in the house
Confined to a room
Crated
Other
Other
*
When left alone, your dog shows the following behaviours? Please check all that apply.
Whining
Barking
Howling
Panic Screaming
Self Mutilates (chews/bites at self)
Foams at the mouth
Urinates
Defecates
Vomits
Injures itself attempting to escape
Shakes and trembles
Excessive scratching
Damages personal items
Damages furniture
Chews at windows/doors
If you checked any of the behaviours above, how long has your dog been exhibiting this behaviour? (Years, Months)
*
Does your dog demonstrates anxiety when family members are away
*
Yes
No
The following changes happened around the time this behaviour began
*
Changed work schedule
Family vacation
Divorce
New baby
Children back at school
New pet
Moved or changed living arrangements
Renovations
There were no changes
Other
Other
*
Have you attempted to crate train your dog
*
Yes
No
If yes, was crate training successful (dog is able to remain in crate without incident)
*
Yes
No
What steps have you taken to control or discourage the above behaviours? Please check all that apply
Basic obedience training
Private training or consultation
Book or internet research
Video/Audio monitoring
Dog walker
Doggie daycare
Consultation with veterinarian
Medication
Punishment
Confinement
Baby gate
Other
Other
*
What type of management measures worked best
*
What worked the least
*
Can your dog stay outside in the yard alone without anxiety
*
Yes
No
Bite History
Has your dog bitten a person with the intention to harm them
*
No
Yes
If yes, did the bite puncture the skin
*
No
Yes
If yes, were stitches required
*
No
Yes
Please explain the circumstances
*
Has your dog bitten another dog with the intention to harm them
*
No
Yes
If yes, did the other dog require veterinary care
*
No
Yes
Please explain the circumstances
*
Has your dog ever demonstrated aggressive behaviour in the following situations? Please check all that apply.
Towards a Human Family Member in the House
Touching the Bowl or Food While Eating
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Touching a Bone, Rawhide, Pig's Ear, etc
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Touching Dog While They are in Possession of a Stolen Food Item (ex. Food From Table/ Counter)
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Touching Dog While They are in the Possession of a Stolen Object (ex. Tissue, Shoe, Sock, etc.)
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Touching Dog While They are in Possession of a Toy
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Petting/Moving the Dog While it is Sleeping
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Removing the Dog off of Furniture
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Approaching the Dog While They are Next to Another Family Member
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Towards an Unfamiliar Person
Stranger Approaches a Family Member
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Stranger Approaches the Yard or House
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Stranger Enters the House
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Stranger Approaches a Vehicle Where the Dog is Inside
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Towards Another Animal
Animal Approaching the Dog's Resources (ex. Food, Toys, Treats, Bed)
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Animal Approaching a Family Member
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Animal Approaching the Yard or House
*
No Aggression
Shows Teeth/Growls
Snaps
Bites
Never Tried
Please feel free to tell us any additional helpful information (favourite toys/games/places, bad habits, if they enjoy swimming, etc.)
Your Name
*
Your Phone Number
Your Email
*
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