Last Name:
First Name:
Email: (name@domain.com)

Home Telephone:  (include area code)   
Work Telephone:  (include area code)    
Cell Telephone:    (include area code)    
                FAX:     (include area code)    

1.                Dog’s Name 
List of nicknames you call the dog: 

2.                Sex 

3.                Reason for surrender

4.                How long have you had this dog? 

5.                Dog’s age:  Date of birth, if known:  

6.                Did you get this dog as a puppy? 
If yes, where did you get the puppy? 

  If no, indicate where and when you obtained the dog:  

7.                Purebred / Mix   
Mixed with?  

   DOB:
 No Yes    If yes, where:

No Yes  If no, mixed with

8.                How many times a day is the dog fed?

9.                What type of food does the dog regularly eat:

10.            How much is the dog fed?

11.            Any known food allergies:
Is there any food that causes an allergic reaction or that does not “agree” with dog? 

12.            Type of “treats” used:

13.            Favorite foods/treats:  

Dry only Dry moistened w liquid Canned only Dry / Canned combination Table scraps Raw Diet Other, please specify   Brand?
If Other:

Cups/Cans of food per meal
 No Yes    If yes, specify: 

Dog Treats - Brand name
Human Treats – Please specify

Please list

Communication and Training

14.            Does the dog understand “English” as its primary language? 
15.            Does the dog respond to or understand hand gestures/signals?  

16.            Please list the words/terms the dog responds to/understands for the following:

17.            List any other phrases/words the dog will respond to or understands, and explain the meaning of each:

18.            Has the dog had any formal obedience training? 

19.            Does dog know basic commands?
 

20.            What terms or sound do you use for the word “NO?” 

21.            Is the dog used to being squirted by a water bottle or used to another type of deterrent for undesirable behavior?

22.            Does the dog know any kind of "tricks" like "roll over" or "speak"?

Yes No     If no, specify: 
Yes No     If yes, specify:

Urinate (i.e., tinkle, wee-wee)
Defecate 
Bed-time 
Ride in the Car 
Other 
 
Yes No     If yes, specify:
Sit      Yes No 
Stay    Yes No 
Down   Yes No 

Yes No   If Yes, what?

Yes No   If Yes, what?

23.            Where did the dog live? 

24.            Did the dog live in:

25.           If dog lived inside, where did he/she sleep?

26.         Was dog allowed on furniture? 

27.           Was the dog left inside or outside when owner was at work or away from the home? 

 28.          If left inside, does dog have access to entire house?

29.            How many hours a day was the dog alone, on average (no human present)?

30.            Is the dog housebroken?

31.            When the dog was let out/taken out to do it's business, was dog:

32.            How often is the dog let out/taken outside?

Rural Urban Suburban

House Apartment Condo Garage Outdoors in Dog House Other If other, please explain:

In its own bed Furniture/Couch Floor Crate Cellar/Basement In bed with a family member

Yes No 

Inside Outside

Yes No N/A Dog is outside

Never Rarely, breif periods Rarely, but can last long periods 4 hours or less 8 hours or less 12 hours or less More than 12 hours

Totally Has infrequent accidents - urinates Has infrequent accidents - Defecates Has infrequent accidents - both Not Housebroken

Walked on a leash Free to roam loose Tied out on rope or cable In fenced in area

0 - lives outside 1 2 3 3 to 5 5 to 7 8 or more

Exercise and Free Time

34.            Does dog enjoy exercise?   Yes    No  If yes, what exercise does dog enjoy?
     

35.            How did you most often exercise the dog?
 Ball throwing
 Frisbee
 Jog/run with owner
 Free roam
 Throw stick
 Coach potato

36.            What type of toys does dog enjoy/play with?  Please list:       
     

37.            Favorite toy:       

Hygiene and Handling:

38.            Where does dog enjoy being scratched?       

39.            Where does dog not like to be touched?       

40.            Please list dog’s “like and dislikes” to the best of your knowledge
                                                                                                              
                                                                                                              
                                                                                                              
                                                                                                              
                                                                                                              

41.            Is the dog tolerant of:
Ears being cleaned    Yes    No
Nails being trimmed  Yes    No
A bath                     Yes    No
Grooming                  Yes    No
Water                     Yes    No

42.            Does the dog like to swim?  Yes    No

43.            Does the dog enjoy car rides?  Yes    No

          Does the dog get motion/car sick?  Yes    No
          If yes, how did you treat/deal with it?  List medication given, if any:      
               

44.            Please describe the temperament of the dog:       

45.            Is the dog “hand shy?”  Yes    No

46.            Does the dog spook easily?  Yes    No

          Please check anything the dog is afraid of:
            Loud noises/voices
           Thunder
           Men
           Cars/car rides
           Veterinarian
           People in uniform
           Certain objects (broom, vacuum, etc.)      
           Other      

47.            Please list any “bad habits” or behavioral problems the dog has:
 Chews furniture/clothing
 Digs holes
 Jumps fences
 Barks excessively
 Bites
 Separation anxiety:  explain what dog does in exhibiting this behavior:
          
 Not compatible with other animals?                                                         

            Dogs

            Cats  
            Other – be specific:      
           Other      

48.            Is the dog ever aggressive?   Yes    No
If yes, please explain:      

49.            Does dog tolerate:
Small children       Yes      No      Don’t Know
Other dogs           Yes      No      Don’t Know
Cats                     Yes      No      Don’t Know
Birds                    Yes      No      Don’t Know
Small animals        Yes      No      Don’t Know
Adults only           Yes      No      Don’t Know
Other                       

50.            Was dog an “only” dog, or in a multiple dog household?  Only   Multiple
List the age and sex of each of the other dogs in the household, and if they were spayed or neutered.                              
                                         

Medical

51.            Spayed     Yes      No  - If no, date of last heat      
Neutered  Yes      No

52.            Has dog ever been bred?  Yes      No      Don’t Know 
If so, when:       
Has dog ever had puppies?  Yes      No 
If yes how many litters, and date of last litter.      

53.            Any problems with eyesight?  Yes      No    

54.            Any problems with hearing?     Yes      No 

55.            Has dog ever been injured?  Yes      No   If yes, please explain:          
     

56.            Has dog ever had a serious illness?  Yes      No
If yes, please explain:       

57.            Does dog have any chronic medical condition?  Yes      No    
If yes, please specify:       

58.            Any known allergies?  Yes      No
 Dust
 Grass
 Fleas 
 Specific Foods – list them:      
 Medicine – specify:      
 Other:      

59.            Is dog current with:
Shots              Yes      No             Date given:      
Heartworm      Yes      No
Rabies             Yes      No              Date given:      

60.            Brand of heartworm preventative being used:      

61.            Date of month given:      

62.            Name, address and telephone of your veterinarian:
     
     
     
Phone:  (       )       

63.            Is dog presently on any medication?  Yes      No
Please list all medications:       

Please feel free to list anything not covered in the above questions that you feel might help us.  We need to know all we possibly can so that we may place the animal in a suitable home.

Thank you for your cooperation.

Northeastern Boxer Rescue

Additional Comments:       

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