About Your Dog
Dog Details / Dogs Name: / Dog ID:Age: / Breed:
Sex: Male / Female / Desexed: Yes / No
Surrender Information / Have staff made you aware of the Dogs’ Home Assessment process?
Why are you surrendering your dog?
If the reason is behaviour, list the behaviour and things that you have tried to solve the issue:
General Lifestyle questions / How old is your dog? Date of Birth if known:
Where did you get your dog?
How long has this dog lived with you?
How often are you home and spending time with your dog? (hours per day spent exclusively with your dog)
What is the longest period of time your dog spends alone? (hours per day)
How does your dog handle being alone?
Where does your dog sleep at night?
Do you trust your dog loose indoors, unsupervised? If not, why?
Is your dog trained? Please give specific detail, including any training clubs attended, year, level graduated from and cues/commands your dog is familiar with:
Is your dog toilet trained?
Has your dog ever used a crate? If so, why was it used:
Household History / Do you trust your dog loose outdoors, unsupervised? If not, why?
Does your dog escape your yard by (please circle):
Climbing Jumping Chewing Digging Other
Height jumped or climbed:
What type of confinement do you have for your dog (height and type of fencing, size of yard available in square metres):
What types of animals has your dog lived/visited/played with? (Please include species, sex and number of animals)
Please describe how the animals get along, ex. Ignores, plays with or exhibits jealousy/bossiness:
Does your dog spend time unsupervised with these pets? If not, why?
When is your dog NOT good with other animals? (describe animal and in what type of situation)
Children / What ages of children has your dog lived/visited/played with?
When is your dog NOT good with children?
When in the presence of children, would you say your dog is (please circle):
Playful Friendly tolerant afraid shy rough not around
Please add any comments about your dog with children:
Other Information / What is the best quality(s) about your dog?
How would you describe your dogs personality/temperament?
List 5 things your dog loves:
1.
2.
3.
4.
5.
Please describe the exercise your dog is given:
How often do you bathe your dog, describe how and does your dog enjoy it? (if a groomer is used, list them)
How often do you trim your dogs nails? Describe how and does your dog enjoy it? (if a groomer is used, list them)
Does your dog travel well in the car?
Please circle the type of travel and restraint:
Ute Tray Seat in Car Crate in car Seatbelt/Harness None
Where does your dog stay when you go on holidays? (If a registered Kennel is used, list them):
Health / Who is your dogs Veterinarian? (Name of Clinic, area or suburb)
Is your dog currently vaccinated? (Please include what vaccinations have been administered)
Is your dog receiving flea or tick control? Please specify brand and when last administered:
Health / Does your dog have an illness or condition? If, yes please list with current treatments provided:
What do you feed your dog? How much per meal? How many meals per day? Treats?
Questions to help handlers and assessment staff / What is your dogs reaction to visitors at the door?
How long does it take your dog to calm down around visitors?
Has your dog ever nipped, growled or bitten anyone? If yes to one or all of these, please tell us who, when and under what circumstance the incident(s) have occurred:
Have any of your dogs bites caused heavy bruising, drawn blood or broken bones? Please be specific and include the part of the body bitten, and whether bites were multiple in one incident or a singular snap like bite. Describe what the person was doing just before being bitten:
Is there any part of your dogs body that he/she does not like to be touched?
What has your dog done to show you he/she doesn’t like those touches?
Have you ever patted/approached your dog while it is eating? Please describe what you have done and what your dogs reaction has been:
Questions to help handlers and assessment staff / Is your dog better or worse, with particular people or children?
Can you take rubbish/ food or stolen items out of your dogs mouth? When you have done so, what was your dogs reaction and how did you take the item away?
Who can safely take items from your dog?
Has your dog done anything that you have had to discipline him/her for? Describe what it was that he/she did wrong, and how you disciplined your dog:
Has your dog ever killed another animal? When, type of animal and how?
Does your dog chase (please circle):
adults kids cats wildlife bicycles other (please list)
Is your dog protective over his/her:
food home/yard family bed car
If yes to any of the above, please circle the best description of how he/she is protective:
Aggressive Cautious Jealous Anxious
Is your dog afraid of anything, including people (example wearing hats/ glasses)?
Does your dog enjoy playing with/ being around water? Please describe his/her reaction to water at the beach, in or near a pool, from a hose etc:
Other Comments / Is there anything else you want to say about your dog?
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