Survey - Pet Guardianship Questionnaire: Dog

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Question - Required - Today's Date:

Month

Day

Year

YOUR INFORMATION

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Name:

Title	First Required	Last Required

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Email: Required

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Street 1: Required

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City/State/ZIP:

City Required	State Required	ZIP Required

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Mobile Phone: Required

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Question - Required - How many adults in the household?

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Question - Required - How many children in the household?

Question - Not Required - Please list ALL other pets residing in your home with whom THIS DOG had contact. Include other pets' species/breed, age, gender, and whether they are spayed/neutered. Also include other pets' relationship with this dog:

YOUR DOG'S INFORMATION

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Question - Required - Breed (lab, lab mix, mutt, etc.):

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Question - Required - Dog's Name:

Question - Not Required - List any nicknames that your dog responds to:

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Question - Required - Dog's Gender:

Male

Female

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Question - Required - Is your dog spayed/neutered?

Question - Not Required - Please provide your dog's microchip number (if applicable):

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Question - Required - Dog's Age (approximately):

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Question - Required - Dog's age when you adopted it (approximately):

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Question - Required - How long have you owned this dog?

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Question - Required - Where did you acquire this dog?

Animal Control

Born at Home

Breeder

Friend / Family

Gift

Newspaper Ad

Pet Store

San Diego Humane Society

Shelter, Rescue, or Other Humane Agency

Stray / Found

Other

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Question - Required - Does your dog have a preference for:

	Men
	Women
	Children
	Cats
	Other Dogs
	Other Animals

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Question - Required - How would you describe this dog, in general?

	Aggressive
	Calm
	Clingy
	Confident
	Cuddly
	Curious
	Dependent
	Excitable
	Fearful
	Friendly
	Happy
	Independent
	Nervous
	Outgoing
	Playful
	Shy
	Smart
	Stand-Offish
	Stubborn
	Submissive
	Vocal
	Other

BEHAVIOR INFORMATION

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Question - Required - How does this dog behave with ADULT members of the household? Select all that apply:

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal

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Question - Required - How does this dog behave with CHILD members of the household? Select all that apply:

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal
	Not Applicable

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Question - Required - How does this dog behave with ADULT visitors to the home?

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal

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Question - Required - How does this dog behave with CHILD visitors to the home?

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal
	Not Applicable

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Question - Required - How does this dog behave with ADULT strangers? Select all that apply:

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal

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Question - Required - How does this dog behave with CHILD strangers? Select all that apply:

	Aggressive
	Calm
	Cuddly
	Destructive
	Excited
	Fearful
	Friendly
	Indifferent
	Playful
	Plays Gently
	Plays Roughly
	Protective
	Shy
	Vocal

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Question - Required - Does this dog enjoy being held, hugged, or handled?

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Question - Required - Has this dog ever bitten anyone?

Question - Not Required - If yes, please explain:

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Question - Required - What makes your dog anxious or worried, or causes it to behave in a different manner than usual?

	Baths
	Brushing
	Car Rides / Getting Into the Car
	Cats
	Children
	Crowds
	Dogs
	Fireworks / Loud Noises
	Getting Nails Trimmed
	Men
	Nothing
	Other Animals
	Strangers
	Vet Visits
	Women
	Other

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Question - Required - Does your dog have separation anxiety?

Question - Not Required - Was the separation anxiety diagnosed by a vet?

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Question - Required - If this dog is kept in a fenced yard or run, how does it behave?

	Barks
	Chews
	Digs
	Digs Under
	Howls
	Jumps Over
	Paces
	Plays
	Rests
	Tries to Escape
	Whines

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Question - Required - When in a fenced yard or run, this dog is friendly with:

	Family
	Visitors
	Strangers

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Question - Required - When in a fenced yard or run, this dog is unfriendly with:

	Family
	Visitors
	Strangers
	None

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Question - Required - Does your dog have any behaviors that you consider to be a problem, or that a future owner should be aware of?

	Aggressive Toward Cats
	Aggressive Toward Dogs
	Aggressive Toward Other Animals
	Aggressive Toward People
	Barking
	Destructive
	Digging
	Jumping on People
	Needy / Clingy
	Nipping
	Separation Anxiety
	Not Applicable
	Other

Question - Not Required - List and explain any actions that were taken to correct the problematic behavior(s):

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Question - Required - Describe your dog's play intensity:

Low / Gentle

Moderate

Medium

High

Very High / Rough & Tumble

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Question - Required - List your dog's favorite toy(s):

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Question - Required - Activities you do with your dog:

	Bathing / Grooming / Brushing
	Games
	Petting
	Play Chase
	Play Fetch
	Play Tug
	Quiet Companionship
	Relaxing / Snuggling
	Restaurants / Cafes
	Road Trips / Running Errands
	Rough-Housing
	Training
	Other

HOUSING AND FEEDING INFORMATION

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Question - Required - This dog is an:

Indoor Dog

Outdoor Dog

Indoor and Outdoor Dog

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Question - Required - Where is this dog when you are HOME?

Inside

Outside

Free Access Inside and Outside

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Question - Required - Where is this dog when you are OUT?

Inside

Outside

Free Access Inside and Outside

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Question - Required - In a 24-hour day, how long is this dog left alone at any given time?

less than 4 hours

4 - 8 hours

8 - 12 hours

12+ hours

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Question - Required - Is this dog a picky eater?

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Question - Required - What type / brand of food does this dog eat? Please specify dry or wet food, and include the brand and any other info:

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Question - Required - How often do you feed this dog?

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Question - Required - What amount is fed per feeding?

Question - Not Required - List any of this dog's favorite treats:

TRAINING INFORMATION

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Question - Required - Is this dog crate trained?

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Question - Required - Is this dog house-trained?

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Question - Required - When does this dog have accidents?

	Frequently
	Only When Left Alone
	Rarely
	Never

Question - Not Required - Accidents Are:

Urination

Bowel Movements

Both

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Question - Required - Where does this dog go potty?

	Litter Box
	Newspaper
	Outside - Let Out By Person
	Outside - Through Dog Door
	Puppy Pads or Similar Product
	Walks
	Yard
	Other

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Question - Required - How do you know when the dog needs to go out?

	Barks
	Goes to Door
	Lets Itself Out
	Paces
	Scheduled Walks
	Other

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Question - Required - Has this dog had obedience training?

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Question - Required - What training equipment has this dog been exposed to?

	Choke Chain / Pinch or Prong Collar / Electronic Collar
	Clicker
	Harness
	Head Halter
	Treats
	Other
	None

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Question - Required - Which behaviors is this dog familiar with?

	Come
	Down
	Fetch
	Heel
	Loose Leash Walking
	Play Dead
	Roll Over
	Shake
	Sit
	Sit Pretty / Beg
	Speak
	Stay
	Other

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Question - Required - Leash Walking Behavior:

	No Leash Exposure
	Pulls on Leash
	Struggles and Bites Leash
	Walks on Loose Leash
	Walks on Tight Leash
	Other

VETERINARY INFORMATION

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Question - Required - Has this dog had routine veterinary care?

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Question - Required - Vet's Name (first and last):

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Question - Required - Name of Vet Office / Practice:

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Question - Required - Vet's Phone Number:

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Question - Required - May we call your vet for information regarding this dog?

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Question - Required - Has this dog received notable veterinary treatment? This does NOT include regular check-ups and care:

Question - Not Required - If yes, please explain:

Question - Not Required - List and explain any medical issues / treatments / care / medications that we should know about:

ADDITIONAL INFORMATION

Question - Not Required - Please list any additional info regarding this dog's daily routine. Include any need-to-know details for walking, feeding, grooming, bathroom time, etc.

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Question - Required - What do you enjoy most about this dog?

Question - Not Required - List and explain any special needs this dog has or any special attention that this dog requires:

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Question - Required - Describe the ideal home you would like for this dog:

Question - Not Required - List any additional info that would be helpful for us or a new owner to know about this dog. This will help us make the best possible match with a new home.