Dog Intake Form - Waggy Butts & Happy Mutts
The following questionnaire provides us with information about how your dog behaved in many different circumstances while he or she was living with you. Because your dog is likely to behave in similar ways in his new home, this information will help us find the most suitable home for your dog and to effectively counsel the new family. Your open and honest answers are very necessary and appreciated so that we can do careful and successful adoptions.
Email
example@example.com
Name
First Name
Last Name
What is the address where the dog is located?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
What is the dog's name?
Is it a male or female?
Male
Female
Age?
Breed?
Weight? (Approx)
Spayed or neutered?
Yes
No
How long have you had this dog?
What is your relationship to the dog?
Where did you get this dog from?
Why are you surrendering this dog?
What other animals did the dog live with?
Please describe the household members who lived with the dog. (Ages, female, male)Your answer
How does you dog usually behave towards the following: People your dog knows
Never Encountered
Friendly
Afraid
Shows teeth/ growls
Snaps
Men
Women
Children
How does you dog usually behave towards the following: Unfamiliar people
Never Encountered
Friendly
Afraid
Shows teeth/ growls
Snaps
Men
Women
Children
How does you dog usually behave towards the following: Unfamiliar animals
Never Encountered
Friendly
Afraid
Shows teeth/ growls
Snaps
Dogs
Cats
Does your dog usually uncontrollably chase or attempt to chase any of the following? Check all that apply.
Joggers
Bicycles
Skateboarders/ roller bladers
Cars/ motorcycles
Cats
Squirrels or other small animals
Birds
Other
How does your dog usually react when an unfamiliar person approaches or enters the yard or house?
Is the dog house-trained (i.e., knows to use the bathroom outside)?
Yes
No/ paper trained
Does your dog usually have “accidents” in the house? If so, how often?
Where does your dog spend most of his/her time?
Inside the house, runs free
inside the house, in crate
outside the house, runs free in the neighborhood
outside the house, in crate/kennel
Outside the house, tied
Other
How long is your dog left alone per day, without people, during the work week?
When your dog is left alone, is he/she...
outdoors
free in home
confined to a room
in a crate
Other
When left alone, does your dog usually show any of the following behaviors? Check all that apply.
destroy household items
urinate/defecate
bark
cry/whine
none of these
When you are home, does your dog usually show any of the following behaviors? Check all that apply.
destroy household items
urinate/defecate
bark
cry/whine
none of these
When your dog plays, does he/she typically….Check all that apply.
jumps
growls
barks
bites lightly
bites hard
none
Other
What toys does your dog like?
Balls
Frisbee
Plush
Squeaky
Tug Rope
Other
What games does your dog like to play with people? (Fetch, tug, chase, wrestling, etc)Your answer
Is your dog scared of anything? If so, what?
Where does your dog sleep at night?
What commands does the dog know?
Has your dog attended any training classes?
How is your dog on a leash?
Is there any report of your dog ever inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)?
Yes
No
Not sure
Other
Has your dog ever attacked another dog resulting in severe injury or death to another dog?
Yes
No
Not sure
Other
Check the appropriate box if your dog has ever shown any of the following reactive behaviors. Do not include reactive behaviors directed toward a veterinarian or groomer
Shows teeth
Growls
Snap
Bite
None
Not sure
Men
Women
Children
Other domesticated animal (cat, rabbit, farm animals, etc)
Explain the circumstances of the snap or bite. If you checked more than one bite in the table above, explain the circumstances of every snap or bite. Your answer
If any reactive behavior to other dogs, men, women, or children was checked in the table above, answer the following questions. If does not apply, mark the Not Applicable box.
Yes
No
Was the reactive behavior over food?
Was it over bones or rawhides or chews?
Was it over toys?
Was it over stolen objects?
Was it when the dog was disturbed while sleeping or resting?
Please specify vet info (if known) and contact info.
Does your dog have to be muzzled at the vet?
Yes
No
Not sure
Does your dog have any past or present medical conditions?
Yes
No
Not sure
What type of food does your dog eat? Your answer
Are you willing to provide a donation to help with our efforts in finding a foster/forever home for your animal?
Yes
No
Feel free to tell us any additional helpful comments.
Please upload photos here.
*
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