Intake Dog History Questionnaire

Dog Name *

Age *

Sex *

Spayed/Neutered *

Breed *

Colour *

In heat/Pregnant/Nursing

ID (Tattoo/Microchip)

Health Information

Does your dog have any past or present medical conditions *

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

If yes, which veterinarian clinic do you use *

Reason For Surrender

Behaviour issue (please specify) *

Other (please specify) *

History

Diet

What do you feed your dog *

Brand of food *

Number of times per day your dog is fed

What is the status of your dog’s appetite

Favourite treats

Food to avoid

Bite History

Has your dog bitten a person with the intention to harm them *

If yes, did the bite puncture the skin *

If yes, were stitches required *

Please explain the circumstances *

Has your dog bitten another dog with the intention to harm them *

If yes, did the other dog require veterinary care *

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 *

Touching a Bone, Rawhide, Pig's Ear, etc *

Touching Dog While They are in Possession of a Stolen Food Item (ex. Food From Table/ Counter) *

Touching Dog While They are in the Possession of a Stolen Object (ex. Tissue, Shoe, Sock, etc.) *

Touching Dog While They are in Possession of a Toy *

Petting/Moving the Dog While it is Sleeping *

Removing the Dog off of Furniture *

Approaching the Dog While They are Next to Another Family Member *

Towards an Unfamiliar Person

Stranger Approaches a Family Member *

Stranger Approaches the Yard or House *

Stranger Enters the House *

Stranger Approaches a Vehicle Where the Dog is Inside *

Towards Another Animal

Animal Approaching the Dog's Resources (ex. Food, Toys, Treats, Bed) *

Animal Approaching a Family Member *

Animal Approaching the Yard or House *

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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