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Dog Profile

* Required fields

*First name:  
*Last name:  
*E-mail:  
*Address line 1:  
Address line 2:  
*City:  
*State:  
*Zip:  
*Phone:  
Dog's Name:  
Breed:  
Color:  
Age:  
Sex:  
Spayed or Neutered:  
Where did you get your dog?  
If other, please specify:  
How long have you owned your dog?
Why are you surrendering your dog to the Humane Society? (Be specific)
Has your dog ever bitten anyone?  
Did the bite break the skin?  
How many times has your dog bitten?  
Explain the circumstances:
How would you describe your dog?
If other, please explain:
Is you dog trained to go outside to pee and poop?  
How many times does your dog go out in a 24 hours period?  
How many hours a day is your dog left alone?  
Where do you keep your dog when you have to leave the house?
Where do you keep your dog when you are home?
Is your dog destructive when left alone?
When left alone does your dog: (check all that apply)
If other, please explain:
How much time on an average day does your dog spend outside?
How often do you exercise your dog and for how long?
How do you exercise your dog?
When allowed outside, your dog was:
If other, please explain:
When outside unsupervised, did your dog: (check all that apply)
If other, please explain:
Does your dog currently live with children?
If yes, what ages:
Have your dog's experiences with children always been positive?
If no, explain:
Describe how your dog plays with kids:
Please select the definition that best describes your dog in the following circumstances.

Very Excited - your dog will bark, whine and jump up on people and objects. Your dog seeks out activity and will chase people or things. Your dog has a hard time calming down and usually has to be removed from whatever is causing the excitement.
Excited - your dog will bark and whine and may jump up on people or objects, but calms within a short time.
Happy - your dog is interested, but very polite. Your dog does not jump up, but will wag his or her tail and approach.
Indifferent - your dog is not interested and does not break away from whatever he or she may be doing.
Anxious - your dog appears to be excited and will approach. Ears are down and his or her tail will be tucked but wagging. Your dog has a very guilty look. Your dog gets so excited or anxious it pees.
Scared - your dog runs away from the situation and attempts to hide under or behind a table or other object. Your dog may eventually approach depending on the circumstances.
Growls - your dog growls in a low tone and may assume a stiff body posture.
Shows Teeth - the lips curl back so that the front teeth can be seen.
Snaps - your dog attempts to bite, but does not bite hard or break the skin.
Nips - your dog bites but does not bite hard enough to break the skin.
Bites - your dog bites, breaks the skin or tears clothing.
Barks - your dog is very vocal.
Don't know - I am not familiar with how my dog will react.
Other - Please explain in the space provided

How does your dog react when:
You or other family members enter the house?  
A male visitor enters the house?   
A female visitor enters the house?  
Children who are visitors enter the house?  
Your dog sees a jogger or a child on a bicycle?  
You take away a favorite toy or bone?  
You take away your dog's food?  
Your dog is disturbed while sleeping in a favorite spot?  
Your dog sees a person of a race other than your own?  
Your dog sees another dog while walking on a leash?  
Additional comments:
Has your dog had any obdience training?
If yes,
Please mark the cues your dog knows:
Would you say that most of the time your dog is (check all that apply):
Does your dog live with other dogs?
If yes, please list the ages of the other dogs.
Does your dog play with other dogs on a regular basis?
Does your dog get along with other dogs?
Has your dog ever been in a dog fight in which either dog was injured?
If yes, explain:
Does your dog live with cats?
If yes, how does your dog get along with cats?
List your dog's fears (check all that apply):
Will your dog let you groom him or her? (bathing and brushing)
Will your dog let you clip its nails?
Does your dog have any medical problems or require medication?
If yes, please explain:
Is your dog current on its vaccinations?
Has your dog been heartworm tested?
How does your dog react when being seen by a veterinarian?
What, if any, behavioral problems does the dog have?
What are two things you like the most about your dog's behavior?



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