Description of your dog Dog Owner s Surrender Questionnaire Please fill out this questionnaire as completely as possible. By filling out this form it allows us to better understand your dog. We are trying to find out a little bit about them so that we may find the best new home fit for them. Please fill it out as completely as possible. Dog s Name: Age: Sex: Male Female Spayed/Neutered? Yes No Breed/s: Microchip? Yes No If yes, chip # Why do you need to give up your dog? If we could help you resolve the issue, would you consider keeping your dog? Yes No Have you tried to find a home for your dog on your own? Yes No Have you contacted any other rescue groups for help in rehoming your dog? Yes No If yes, who: Have your dog bitten or snapped at someone in the last 10 days? Yes No If yes, did it break the skin? Yes No If yes, describe the circumstances: How long have you owned this dog? If this is not your dog; who owns the dog? Including yours, how many homes has this dog been in? Where did you get the dog from? Breeder Friend/relative Humane Society (name) Pet Store Advertisement Another shelter/rescue (name) Born at Home Found Stray Other Family Environment Please describe the dynamics of your family that your dog has lived with on a regular basis (check all that apply) Adult Males Adult Women Senior Citizens Children (0-5) (5-10) (10+) Did you have children visit your home on a regular basis? Yes No If yes, what were the ages of the children: Page 1 of 10
Describe your dog s behavior around children (check all that apply): Gentle friendly/playful Nervous/frightened Unpredictable Ignores Roughhouses Watches over children Snappy at times Too Rough Too active Actively avoids children Never been around children Other (explain) Would you recommend your dog to be placed in a home with children? Yes No If no, why? if yes, ages? Children (0-5) (5-10) (10+) Has your dog been in contact with or lived with other animals? (Check all that apply) Male dogs Female dogs Cats Birds Small animals (kind?) Rabbits Reptiles Farm Animals (kind?) Other? Describe this dog s behavior around other dogs (check all that apply) Never been around other dogs Frightened Friendly/playful Ignore other dogs Aggressive towards- All dogs Male dogs Female dogs Small dogs Large dogs Roughhouses Good with some dogs/not all Gentle/submissive Aggressive on leash Aggressive in yard Bossy Adores other dogs Other: Would you recommend that this dog be placed with another dog? Yes No In no, why? Describe behavior around cats (check all that apply): Never been around cats Respectful Friendly/playful Chases to harm Ignores Frightened Gentle/ submissive Chases to catch Aggressive Roughhouses Chases for fun Has killed a cat Other Would you recommend that this dog be placed with a cat? Yes No In no, why? Home Environment & Manners When you were gone for the day, where did you keep your dog? (Check all that apply) In a crate free run of the house Garage Outdoor Kennel In one room Tied outside In a fenced yard Other Page 2 of 10
Where does your dog sleep at night? (check all that apply) In Owner s bed In children s bed Anywhere they want In a crate Outside kennel In fenced yard Garage On a dog bed Confined in a room Other How many hours a day is your dog typically outside (check one)? None, lives only indoors less than 1 hour 1-3 hours 4-6 hours 7-10 hours Only outside at night lives outdoors, never been inside Other How is your dog confined to your property when outside (check all that apply) Fenced yard kennel or enclosure Tied out on a rope or chain Dog House Electric fence Never left alone outside Other Does your dog jump fences? Yes No How tall is your fence? Feet Has your dog ever escaped his confinement? Yes No If yes, where did your dog go? When your dog is outside, was s/he ever teased or bothered by people or other animals? Yes No If yes, please explain? If your dog was kept tied on a rope, chain or runner; did s/he ever do any of the following (check all that apply)? Escape the rope, chain, runner Pace Annoy neighbors Get tangled in the rope Dig Become protective of the space Bark, whine, howl or cry Was calm Was never tied or chained Other Is your dog housetrained? Yes, never goes in house Yes, but will poop Yes, but will pee Used to be, not now No, goes in house Outside dog- never in the house If your dog does have housetraining accidents, they most often happen when (check all that apply)? When dog is not supervised When dog is not on a schedule when dog is kept inside too long When s/he greets people when dog is sleeping When overexcited submissively Other: How have you dealt with housetraining problems (check all that apply) Rubbed nose in it Confines dog inside made dog feel guilty/ acted mad at dog Page 3 of 10
Yelled at dog Kept dog outside consulted vet/trainer spanked or swatted dog Crated dog Other Is your dog crate trained? Yes No Tried, but didn t like the crate Tried, but broke out If yes, how long does your dog spend in the crate each day? Can your dog be left alone in the house for 8 hours a day without issues? Yes No Never tried If no, Why not? Is your dog destructive when left alone (if, yes check all that apply)? Yes No Chews: woodwork/walls furniture windows/doors clothing/shoes other items Is not left alone in house digs or destroys yard Other When left alone in home, does your dog annoy the neighbors? Yes No I don t know Is your dog allowed to sit/sleep on furniture? Yes No Does your dog raid the trash or get into similar mischief? Yes No Does your dog steal unattended food and/or objects from counters or tables? Yes No If yes, how have you dealt with this issue? Does your dog beg at the table? Yes No If yes, is this rewarded with food? Yes No Obedience, Exercise, Play and Behavior What kind of training does your dog have? I did training myself a Home Dog Trainer Puppy classes Obedience classes Board and Train Advanced Training (agility, flyball, etc) No training Where and when? How often do you work with your dog on manners/training? Daily Weekly Not since classes Rarely Never Please tell us about desirable tricks or habits that you have taught your dog to do (check all that apply)? Basic obedience commands come when called Play fetch Walk on a loose leash Greets visitors politely Wait for food Shake or similar tricks Take treats gently Get on and off furniture when asked rides nicely in car Other Page 4 of 10
What words does your dog understand? Sit Down Stay Heel Come Drop Leave it take it Wait Off Free/release Doesn t know any commands Other Can your dog be allowed off-leash and come when called? Yes No Does your dog jump up on people when greeting them? Yes No What type of exercise does your dog get on a regular basis (check all that apply)? Accompanies owner running/jogging Walking on a leash Fetch Dog park Accompanies owner walking/hiking Not enough exercise for my dog Plays with kids Plays with other dogs doggie daycare Other What are your dog s favorite kind of toys (check all that apply)? Tennis balls/rubber balls Rope toys Shoes Plush/stuffed toys Frisbee Sticks Squeaky toys children s toys Other Describe your dog s play style with people (check all that apply)? Plays gentle enjoys tug of war enjoys wrestling prefers fetch prefers to chase Tends to herd/nip plays rough, doesn t stop when told Jumps and uses mouth to play Plays respectfully Plays very physically No interest in playing with people Other Describe your dog s play style with other dogs (check all that apply)? Plays gentle adapts to others play styles barks constantly will play with all dogs Plays chase with little body contact shares toys and plays quietly Tends to herd/nip others during play plays hard with a lot of body contact Jumps and uses mouth to play does not enjoy playing with dogs Has never played with other dogs Will not share toys Plays very physically No interest in playing with other dogs Other How does your dog react to being handled or corrected by the collar (check all that apply)? Acts calm and accepting Offers strong resistance Growls or barks Yelps or cries Cowers or acts frightened snaps, mouths, or bites Lies down Never tried Page 5 of 10
Other Please describe your dog s behavior in the car (check all that apply)? Calm Nervous Gets car sick Protective of car destructive Never rides in car Is your dog protective of the following (check all that apply)? Of food (towards people) Of toys (towards people) Of his/her body Of property Of food (with other animals) Of toys ( with other animals) Of owner/family Of bed, crate, or space Dog is not possessive or protective Other Please select all of the following that frighten your dog (check all that apply)? Men School-aged children Babies or Toddlers Teenagers Women Loud Noises Unpredictable children Strangers/Visitors People in uniform Fireworks Vet or groomer Cars Erratic or sudden movement Yelling Thunder/lightning Vacuum Broom Bikes/skateboards Other Please identify if your dog has ever done any of the following (check all that apply)? Adult family members Children family members Strangers at door Visiting adults Visiting children Vet or Groomer People near his/her food or treats People near his/her sleeping area Pedestrians People in Uniform Wildlife Friends or neighbors pets What does your dog do when it sees wild animals like squirrels, raccoons, opossums (check all that apply)? Never sees a wild animal ignores Tries to play with Barks or Growls Kills Watches intently and/or silently Is afraid of chases stalks Other Page 6 of 10
Does your dog ever run after cars, bikes, skateboarders, or pedestrians? If yes, please explain Diet, Health, and Grooming Does your dog eat: Wet food only Dry food only Combination Human food Raw Diet What brand of food does your dog eat? How often does your dog eat? Once a day Twice a day Always available Other Does your dog receive treats on a regular basis? Is your dog fed scraps from the table or people food? Does your dog have allergies or sensitivities to any grains or common food ingredients? If yes, which ones? I don t know If yes, what happens to your dog? How does your dog react to seeing your dog s veterinarian (check all that apply?) Loves it Tolerates it hates it Nervous Needs to be muzzled for vet Never seen vet Name and location of your dog s Veterinarian: Please indicate which vaccines your dog has had and the date of the most recent vaccinations: DHLPP Rabies Bordatella Leptovirus never vaccinated Has your dog ever undergone surgery? If yes, please explain: Has your dog ever been diagnosed or treated for any of the following by a vet (check all that apply): Heartworm disease Parvovirus Heart murmur Epilepsy or seizures allergies Thyroid disease Arthritis or hip dysplasia Diabetes Separation anxiety Broken Bones Chronic ear/eye infections Diabetes Thyroid disease Tumors Mange or other skin problems Chronic diarrhea/ vomiting cancer Hit by a car none, my dog has always been healthy Other illness/ condition Does your dog require any medication on a regular basis? If yes, please explain Page 7 of 10
Has your dog ever been professionally groomed or bathed? If yes, how did your dog behave Does your dog allow you to bath him/her? Does your dog allow you to brush him/her? Does your dog allow you to clip his/her nails? Never tried Never tried Never tried Are there any places on your dog s body that s/he does not like to be touched, brushed or petted? If yes, please explain Has your dog ever been boarded or kenneled at a: Private boarding kennel Veterinarian Animal Shelter Never been boarded If yes, how did your dog react to being boarded/kenneled? Other What makes your dog the happiest? What upsets your dog the most? What else should we know about your dog so we may find it the best home? Page 8 of 10
Planned Pethood, Inc. Owner Surrender Dog Release Surrender Fee Received- Amount$ If applicable, reimbursement for medical costs, medications or care received PPI agent initials PPI agent initials This is a service to help place dogs/cats in new homes when their present owners can no longer keep them. Your donation will help pay for expenses. I,,hereby surrender, the animal named, to Planned Pethood, Inc. I certify that I am the owner of this dog, free and clear of all other interests. I certify that this dog is not possessed of any dangerous or vicious propensities, and that I have not willfully concealed information about the dog that might indicate such propensities. The information I have provided about this dog is true and complete. I understand and agree to the terms set forth by having answered the questions above to the affirmative. I hereby forever release, discharge and agree to hold harmless and indemnify PLANNED PETHOOD, its board of directors, its members, officers, and agents from all claims, demands, actions, causes of action, or liability of any kind whatsoever arising as a result of or in connection with the adoption or other disposition of the above named dog. OWNER'S NAME: SIGNED BY OWNER: DATE: VET RECORDS RECEIVED BY DATE: Page 9 of 10
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