Connecticut Humane Society Canine Pet Personality Profile
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- Judith Wheeler
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1 Connecticut Humane Society Canine Pet Personality Profile Employee Conducting the Evaluation: The following questionnaire is used to help us learn about your dog. We use this information to help find the best possible home and prepare your pet s new family with information about his/her history. Please complete this questionnaire as completely and accurately as possible. Undesirable behaviors or medical issues do not necessarily prevent placement, but failure to disclose them does. Reason for surrender: Surrendering Person s Relationship to Dog: BASIC INFORMATION: 1. Dog s Name: 2. Age or DOB: 3. Breed: 4. Sex: Male Female 5. Is this dog spayed or neutered? Yes No 6. If yes, at what age? 7. Microchip Company and # (if applicable): 8. Where did you get this pet? CT Humane Society Other Rescue Giveaway Animal Control Breeder Found Stray Pet Store Offspring from Pet Relative Friend Abandoned 9. How long have you owned this pet? 10. If you got this dog from a previous owner, why did he/she give this away? HEALTH CARE: 1. What veterinary hospital/veterinarian cares for this pet? Phone/Town: 2. How does this pet react at the vet? (Check all that apply) Calm Nervous Excited/Hyper Needs muzzle Needs sedation prior to visit Friendly 3. Is this pet on any medication or special diet? Yes No Details: 4. Does this pet have any present or past medical conditions? This will better help our Medical team assist your pet. Yes No Details: 5. Is your dog up-to-date on vaccinations? Yes No Details: 6. Does your dog have any allergies, including food, flea or a history of allergic reactions to vaccinations? Yes No Details:
2 7. What type of food does your dog eat? Brand: Dry Wet Mix 8. How often is your dog fed? Morning Evening Morning and Evening Free Fed 9. What types of treats/food do you give your dog as a special treat? 10. How does your pet typically react when groomed? Never tried/unknown Enjoys Allows Nervous Shows teeth/growls Snaps/bites Needs muzzle Other: HOUSEHOLD INFORMATION AND SOCIAL BEHAVIOR: 1. Including yourself, please record all individuals who live with this dog and their ages: Name/Relationship Age Gender Notes 2. What animals currently live with this dog? Dogs (note breed/sex/age): Cats Birds Small Animal Reptile 3. How does your dog typically behave toward the following? Please check the boxes. Unknown Friendly Fearful Shows teeth/growls Snaps Bites Other People your dog knows Men Women Children Unfamiliar people Men Women Children Animals your dog knows Dogs Cats Unfamiliar animals Dogs Cats If other is checked for any category, please specify and explain:
3 4. How would you describe your dog s personality? Check all that apply. Playful Couch Potato Vocal Friendly Shy Independent Fearless Fearful Quiet Affectionate Hyper Aloof 5. How does your dog typically respond when an unfamiliar person approaches or enters the yard or house? Friendly Afraid Barks Shows teeth/growls Snaps/bites Details: 6. How active is this dog? Very active Somewhat active Inactive 7. How vocal is this dog? Very vocal Somewhat vocal Non-vocal 8. Does your dog like to chase any of the following? Joggers Bicycles Cars/Motorcycles Skateboarders/Roller bladers Outdoor cats Indoor cats Birds Wildlife 9. Does your dog have any bad habits (i.e. stealing food, raiding the trash, etc.)? 10. Is your dog frightened of anything (i.e. fireworks, etc.)? 11. How does this dog behave in the car? Loves it! Puts head out window Gets car sick Scared Calm/Quiet Jumping/Hyper ROUTINE: 1. Does this pet live indoors or outdoors? Indoors Outdoors Both Details: 2. Where does your dog spend most of his/her time? Loose inside the house Crated inside the house Loose outside Tied out in the yard In fenced yard Outside in a run/kennel 3. Is this pet housebroken? Yes No 4. Does your pet have accidents in the house? Yes No Crate trained? Yes No How often? Daily Weekly Once in a while Paper trained Yes No 5. How does your pet let you know he/she has to go out? 6. How many hours is this pet left alone per day? Never 1-3 hours 4-8 hours 9-12 hours Over Where does your dog stay when alone and why? 8. When left alone, does your dog display any of the following behaviors? Destroys household items Urinates/defecates Barks for long periods of time Breaks out of crates Destroys furniture/home None of these
4 9. Where does your dog typically stay at night and why? 10. What are your dog s favorite games and toys? 11. When playing, does your dog do any of the following? Check all that apply. Jump Growl/Vocalize Bark Mouths/Bites lightly Bites hard None of these 12. Is your dog allowed on furniture? Yes No 13. Please include any other pertinent routine information: TRAINING: 1. What commands does your dog know? Sit Stay Down Come Heel Give paw Does your dog perform these reliably? Yes, all the time No, he is unreliable Yes, if I have a treat Yes, if I have a toy No, not when he s distracted No, not when he s outside 2. Has your dog attended any obedience training classes? Yes No Details: 3. Has your dog attended a boarding or daycare facility? Boarding Daycare No Details: 4. Has your dog ever been walked on leash? Yes No Details: 5. When off leash, does your dog return when called? Yes No Sometimes Never allowed off leash 6. Has your dog ever escaped your property? Explain. BEHAVIOR: 1. Has your dog ever bitten anyone? Yes No Date of bite: 2. Did this bite break skin? Yes No Details: 3. Has your dog ever snapped at anyone? Yes No Details: If yes, did this behavior occur when the dog was in pain? Yes No If yes, did this behavior occur when someone was breaking up a dog fight? Yes No 4. Has your dog ever attacked another animal? Yes No Details:
5 5. Does your dog bark, growl or snap when strangers approach him/her? Yes No Details: 6. Please check the appropriate boxes if your dog has ever been aggressive in the following situations with the following types of people: Men Women Children No history of this behavior Aggressive over food Aggressive over bones/rawhides/chews Aggressive over toys Aggressive over stolen objects/food items Aggressive when sitting next to or on a family member Aggressive when moved off furniture If any of the boxes were checked, please explain the situation(s) in detail: STAFF ONLY BELOW THIS POINT BEHAVIORAL INTAKE SUMMARY O/G Surrender Witness No Admit/Request Evaluator: Category Range A B C D F Range Social Int. Friendly Aggressive Body Lang. Soft eyes/body Lunging/Growling/Snapping Stress Level Calm Shedding/Displacing/Avoidance Food Bowl Leaves Food to Greet Leaves Bowl to Bite Toy No interest in toy Leaves Toy to Bite Resources No Interest in bone Leaves Bone to Bite
6 A = Soft, gentle, friendly, people motivated, solicitous, placid, inviting B = Relaxed, friendly, raised paw, lip licking, solicitous, slightly more exuberant than an A dog, may appear apologetic if startled C = Independent, maybe a bit rough, reactive, aroused, mouthy, exhibits some displacement such as sniffing, climbing D = Stiffens, freezes, cautious, tentative, highly aroused, kinetic, serious, very rough (brutal), height seeking body checking F = Lunging, snapping, combative, sustained eye contact, hard eye, tight mouth, bite attempt For Intake History, record owner responses below. Intake Hist. Loves Children Loves Dogs Loves Cats No Medical Issues Has / Will Lunge Or Show Aggression Has / Will Attack Dogs Has / Will Attack Cats Medical Approval Required Notes:
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CAT QUESTIONNAIRE. This will help determine the possible cause(s), prognosis and management plan for their behaviour problem(s).
CAT QUESTIONNAIRE Please answer the following questions as thoroughly as possible to help describe the environment, social interactions, history and behaviour of your cat. This will help determine the
Canine Behaviour Consultation Form
1 / 10 Canine Behaviour Consultation Form Please fill out this form as completely and accurately as possible. The information you provide is important in diagnosing and treating your pet s behaviour problem.
Pawswise Client Questionnaire
Pawswise Client Questionnaire The questions are below. Please give as much detail as you can, describing what you can actually see, rather than what you think, believe or suspect your dog is thinking/feeling.
Enrollment Form, Pet Profile and Liability Release. Enrollment Form
Enrollment Form, Pet Profile and Liability Release A completed Enrollment Form and Pet Profile must be submitted for each pet attending Timberlane Pet Hospital & Resort before an interview is scheduled.
Name: Address: Dog s Name: Spayed/Neutered. Yes No. How long have you had the dog? Where was the dog acquired?
Name: Address: Email: Dog s Name: Dog s Age: Dog s Breed: Male Female Spayed/Neutered Yes No How long have you had the dog? Where was the dog acquired? Breeder Rescue Shelter Friend/Family/Acquaintance
Cat Behavior Questionnaire
Date/time of appointment: Cat Behavior Questionnaire Please complete this form using black ink and return it by fax, mail, or e-mail. The return of this form is a CRUCIAL part of your pet s appointment.
Canine Behavioral Assessment & Research Questionnaire (short version)
Canine Behavioral Assessment & Research Questionnaire (short version) SECTION 1: Excitability INSTRUCTIONS: Some dogs show little reaction to exciting events, while others become highly excited at the
Dog Evaluation Forms
Dog Evaluation Forms EVALUATION OF OWNER SURRENDER DOGS Evaluation done by: Your Email: Phone number that is best to reach you if we have questions: Date of Evaluation: To which state is this form going?
ADOPTION APPLICATION
ADOPTION POLICY The Pet Adoption Center of Orange County (PAC-OC) seeks permanent, loving homes where our rescued dogs can live a long, happy and healthy life as part of a family. Adoptive families must
Adoption Application
CONTACT INFORMATION Name: Address: Phone: Email: Are you a current or former WagsInn customer? Yes No HOUSING Do you live in a house, condo, apartment, or townhouse? Do you rent or own? If you rent, please
Mental Development and Training
Mental Development and Training Age in Weeks STAGE 1 0-7 Puppy is learning good potty habits, bite inhibition, and playing with other dogs. This is where much of the dog s confidence and trust is developed.