Dog Intake Questionnaire Date Date Format: MM slash DD slash YYYY Name* First Last Phone*Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Select* Stray Owner Surrender How many dogs/puppies are you surrendering?*Dog's Name and Gender (If more than one, please list all.)Approximate Age:Breed:Please select all that apply: Spayed/Neutered Microchipped Reason for surrender? (Please explain.)*How long have you been caring for this dog?*Where did you acquire this dog?*Has this dog been seen by a veterinarian? Yes No Veterinarian's Name:Please list and explain any health issues we need to be aware of:House trained? Yes No Somewhat, still learning. Crate trained? Yes No No longer needs a crate. Where does this dog primarily live? Indoors Outdoors (fenced in yard) Outdoors (tied out) If kept outdoors, how many hours per day?Can this dog be left alone in the house without problems? (Please explain.)Please describe any destructive tendencies or separation anxiety:Please select all that apply:* Good with children Good with men Good with women Unknown (stray) Please select all that apply:* Good with other dogs Not good with other dogs Somewhat good with other dogs, can be selective Good with cats or other small animals Unknown (stray) Are you able to safely remove food, toys, or other items? Yes No Sometimes, depending on the item Activity Level: Very high (needs lot of exercise) High Medium (happy with a short walk) Low Please list any commands your dog(s) know:Please select all that apply: Barks when left alone Allowed on furniture Crated when alone Accustomed to eating dry food Accustomed to eating canned food Has your dog ever bitten anyone?* Yes, provoked Yes, unprovoked No Unknown (stray) Has your dog ever growled at anyone?* Yes No Unknown (stray) Has your dog ever snapped at anyone?* Yes, provoked Yes, unprovoked No Unknown (stray) If you answered yes to any of the above questions, please explain.What else would you like for us to know about this dog?
