Connecticut Humane Society – Canine Foster Report Card

Dog’s Name: ______ID #:______Employee Conducting the Intake:

The following questionnaire is used to help us 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.

HOUSEHOLD INFORMATION AND SOCIAL BEHAVIOR:

1. When you first brought your foster dog home, how did it react? o Friendly/Affectionate o Aloof o Scared

2. After adjusting to your home, how was your foster dog? o Friendly/Affectionate o Aloof o Scared

3. Including yourself, please record all individuals who lived with this dog and their age range:

Name/Relationship
(first name only please) / Age Range
(0—7) (8-15)
(16-21) (21-65) (65+) / Gender / Notes

4. Did your foster dog interact with other pets in the home? o Dogs (note breed/sex/age):

o Cats o Birds o Small Animal o Reptile o Other:

  • 5. How did your foster 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:

  • 6. How would you describe your foster dog’s personality? Check all that apply. o Playful o Couch Potato o Vocal

o Friendly o Shy o Independent o Fearless o Fearful o Quiet o Affectionate o Hyper o Aloof

o Other:

  • 7. How does your foster dog typically respond when an unfamiliar person approaches or enters the yard or house?

o Friendly o Afraid o Barks o Shows teeth/Growls o Snaps/bites o Other:

Details:

8. How active is this dog? o Very active o Somewhat active o Inactive

9. How vocal is this dog? o Very vocal o Somewhat vocal o Non-vocal

  • 10. Does your foster dog like to chase any of the following? o Joggers o Bicycles o Cars/Motorcycles

o Skateboarders/Roller bladers o Outdoor cats o Indoor cats o Birds o Wildlife o Other:

  • 11. Does your foster dog have any bad habits (i.e. stealing food, raiding the trash, etc.)?
  • 12. Is your foster dog frightened of anything (i.e. fireworks, etc.)?

13. How does this dog behave in the car? o Loves it! o Puts head out window o Gets car sick o Scared

o Calm/Quiet o Jumping/Hyper o Other:

ROUTINE:

1. Is this dog housebroken? o Yes o No 2. Did your foster dog have accidents in the house? o Yes o No

Crate trained? o Yes o No How often? o Daily o Weekly o Once in a while

Paper trained o Yes o No

3. How did your foster dog let you know he/she has to go out?

4. How many hours was this dog left alone per day? o Never o 1-3 hours o 4-8 hours o 9-12 hours o Over 12+

5. Where did this dog stay when alone and why?

  • 6. When left alone, did your foster dog display any of the following behaviors? o Destroys household items

o Urinates/defecates o Barks for long periods of time o Breaks out of crates o Destroys furniture/home

o None of these o Other:

7. Where did your foster dog typically stay at night and why? ______

8. What are your foster dog’s favorite games and toys?

  • 9. When playing, did your foster dog do any of the following? Check all that apply. o Jump o Growl/Vocalize

o Bark o Mouths/Bites lightly o Bites hard o None of these o Other:

10. Was your foster dog allowed on furniture? o Yes o No

11. Please include any other pertinent routine information:

TRAINING:

1. What commands does your foster dog know? o Sit o Stay o Down o Come o Heel o Give paw

o Other:

Does your foster dog perform these reliably? o Yes, all the time o No, he is unreliable o Yes, if I have a treat

o Yes, if I have a toy o No, not when he’s distracted o No, not when he’s outside

2. When off leash, does your foster dog return when called? o Yes o No o Sometimes o Never allowed off leash

3. Has your foster dog ever escaped your property? Explain.

  • BEHAVIOR:

1. Has your foster dog ever bitten anyone? o Yes o No Date of bite:

2. Did this bite break skin? o Yes o No Details:

3. Has your foster dog ever snapped at anyone? o Yes o No Details:

If yes, did this behavior occur when the dog was in pain? o Yes o No

If yes, did this behavior occur when someone was breaking up a dog fight? o Yes o No

4. Has your foster dog ever attacked another animal? o Yes o No Details:

5. Does your foster dog bark, growl or snap when strangers approach him/her? o Yes o 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:

ADOPTION MEMO:
Please write a few sentences about your dog for use in their Adoption write-up.
______

______

______

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
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.
Loves Children / Has / Will Lunge Or Show Aggression
Intake Hist. / Loves Dogs / Has / Will Attack Dogs
Loves Cats / Has / Will Attack Cats
No Medical Issues / Medical Approval Required
Notes: