Support NHS

*1.

Question - Required - Please indicate the reason for surrender:
Please make at least 1 selection from the choices below.

	I cannot afford pet food/supplies
	I cannot afford vet care
	The pet has behavior issues
	Pets aren't getting along in the home
	I no longer have stable housing/I have landlord issues
	I'm moving and cannot take the pet
	I'm in the military and being deployed
	I'm fleeing a domestic violence situation
	I've been caring for a pet abandoned by its owner
	I (or the pet's owner) have fallen ill
	the pet's owner is deceased
	I have no time for a pet
	I have too many pets
	COVID-19 related
	Other

*2.

Question - Required - We may have alternatives to help keep your pet in your home or provide you with information to find him or her a new home without having to enter the shelter. Would any of the following resources help you be able to keep your pet in the home? Check all that apply:
Please make at least 1 selection from the choices below.

	Pet food and supplies assistance
	Low-cost spay and neuter
	Pet Medications
	Pet Medical Care
	Vaccines
	Assistance with vet care cost
	Behavior and training assistance
	How to rehome my pet myself
	Pet-friendly housing
	Temporary Foster Care/Boarding
	Other
	No, I want to surrender

DESCRIPTION AND BASIC HISTORY

*3.

Question - Required - What is the dog's name?

*4.

Question - Required - How old is the dog?

*5.

Question - Required - What is the dog's breed?

*6.

Question - Required - What color(s) is the dog?

*7.

Question - Required - What sex is your dog?

*8.

Question - Required - Is your dog spayed/neutered?

*9.

Question - Required - Is your dog microchipped?

*10.

Question - Required - If yes, who is the microchip registered to?

*11.

Question - Required - Where did you get your dog?

12.

Question - Not Required - If you got your dog from a shelter, rescue or other, please tell us specifically where from.

(Maximum response 255 chars, approx. 5 rows of text)

*13.

Question - Required - How long have you had your dog (please specify in years, months, etc.)

(Maximum response 255 chars, approx. 5 rows of text)

*14.

Question - Required - Including yours, how many homes has your dog had?

*15.

Question - Required - Has your dog bitten a human, breaking skin, within the last 10 days?

*16.

Question - Required - Including yourself, what are the ages and sexes of people who have lived in the home with the dog?

*17.

Question - Required - Do children that don't live with you visit your home frequently? If yes, what ages and how often do they visit?

*18.

How would you describe your dog with children?

(Select one of the available choices or enter a different value.)
Question - Required -

*19.

In your opinion, what ages of children would live safely and happily with this dog?

(Select one of the available choices or enter a different value.)
Question - Required -

*20.

Question - Required - What other animals has your dog lived with? (Check all that apply)
Please make at least 1 selection from the choices below.

	Large male dogs
	Large female dogs
	Medium male dogs
	Medium female dogs
	Small male dogs
	Small female dogs
	Cats
	Birds/small pets
	None
	Other

*21.

Question - Required - If others, please list them here:

(Maximum response 255 chars, approx. 5 rows of text)

*22.

Question - Required - Does your dog get along with other pets in the home?

(Maximum response 255 chars, approx. 5 rows of text)

*23.

Question - Required - If no, is this dog the resident dog or the newest addition?

*24.

Question - Required - What kind of housing has your dog lived in?

*25.

Question - Required - When alone, where is your dog kept?

	Indoor kennel/crate
	Indoors unconfined
	Room within house
	Outdoor kennel
	Outdoor yard
	Other

26.

Question - Not Required - Where is your dog generally kept?

*27.

Question - Required - How long is your dog left alone during the day?

28.

Question - Not Required - When left alone, does your dog display any of the following behaviors? (check box all that apply)

	Destroy household items
	Urinate/defecate
	Bark/howl
	Cry/whine
	Drools/pants
	No behavior issues when left alone
	Other

29.

Question - Not Required - If other, please indicate any other behaviors here:

(Maximum response 255 chars, approx. 5 rows of text)

*30.

Question - Required - If your dog is crate trained, how long does your dog spend in a crate on an average day?

*31.

Question - Required - If your dog is not potty trained, please check all that apply
Please make at least 1 selection from the choices below.

	Urinates inside daily
	Urinates inside occasionally
	Defecates inside daily
	Defecates inside occasionally
	The dog is potty trained

*32.

When do most accidents occur?

(Select one of the available choices or enter a different value.)
Question - Required -

*33.

How is your dog confined to your property when outside?

(Select one of the available choices or enter a different value.)
Question - Required -

*34.

Question - Required - If fenced, what type of fence and how tall?

(Maximum response 255 chars, approx. 5 rows of text)

*35.

Question - Required - On a typical day, how much time does your dog spend outside?

36.

Question - Not Required - When unsupervised outside, does your dog do any of the following?
Please make at least 1 selection from the choices below.

	Digs holes
	Chases small animals
	Escapes
	Barks continuously
	Barks at other dogs
	Barks at strangers
	Other
	My dog does not display any of these behaviors

37.

Question - Not Required - If other, please describe the behavior below:

(Maximum response 255 chars, approx. 5 rows of text)

*38.

Question - Required - Does your dog display destructive behaviors?

39.

Question - Not Required - How often does your dog chew in a destructive manner?

40.

Question - Not Required - How often does your dog dig?

41.

Question - Not Required - How often does your dog scratch?

42.

Question - Not Required - Do the aforementioned behaviors occur only when left alone?

43.

Question - Not Required - Where does your dog sleep at night?

44.

Question - Not Required - Does your dog do any of the following while playing? (Check all that apply)
Please make at least 1 selection from the choices below.

	Growl
	Bark
	Bite gently
	Bite hard
	Chase
	None
	Other

45.

Question - Not Required - What toys does your dog like? (Check all that apply)

46.

Question - Not Required - What games does your dog like? (Check all that apply)

	Fetch
	Tug
	Chase
	Wrestling
	Hide & Seek
	My dog does not play games
	Other

47.

Question - Not Required - Is your dog afraid of anything? If yes, please specify.

48.

What types of exercises does your dog receive on a regular basis? (Check all that apply)

(Select one of the available choices or enter a different value.)
Question - Not Required -

49.

Question - Not Required - What are your dog's best qualities?

BEHAVIOR AND TRAINING

50.

Question - Not Required - Have you taken your dog to training classes or worked with a trainer?

*51.

Question - Required - If yes, give the name of the trainer (if applicable) and describe the training methods used

52.

Question - Not Required - What commands does your dog know? (Check all that apply)

	Sit
	Down
	Stay
	Shake/High Five
	Heel
	My dog doesn't know any commands
	Other

53.

Question - Not Required - Has your dog ever been on a leash?

54.

Question - Not Required - Describe your dog's behavior in the car

	Enjoys
	Calm
	Gets sick
	Nervous/fearful
	Tolerates
	Never rides in car

How does your dog usually behave with the following?

55.

Question - Not Required - Familiar Men Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

56.

Question - Not Required - Familiar women Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

57.

Question - Not Required - Unfamiliar men Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

58.

Question - Not Required - Unfamiliar women Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

59.

Question - Not Required - Babies Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

60.

Question - Not Required - Toddlers Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

61.

Question - Not Required - Children Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

62.

Question - Not Required - Other dogs Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

63.

Question - Not Required - Cats Calm
Friendly
Playful
Fearful/Nervous
Ignores/Avoids
Barks
Growls
Snaps
Bites
Never Encounters

64.

Question - Not Required - How many times has your dog snapped at someone? (Warning bite that doesn't make contact with skin or clothes). Please specify if they were adults or children.

(Maximum response 255 chars, approx. 5 rows of text)

65.

Question - Not Required - How many times has your dig bit a person? Please specify if they were children or adults.

(Maximum response 255 chars, approx. 5 rows of text)

66.

Question - Not Required - Have these bites broken skin to cause bleeding?

(Maximum response 255 chars, approx. 5 rows of text)

67.

Question - Not Required - Please describe any bite incident(s) and give the approximate date when they occurred.

How does your dog react to the following?

68.

Question - Not Required - People touching/taking food, bones, toys, other items

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

69.

Question - Not Required - Other pets touching/taking food, bones, toys, other items

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

70.

Question - Not Required - Familiar people approaching owner/family

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

71.

Question - Not Required - Unfamiliar people approaching owner/family

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

72.

Question - Not Required - Familiar people entering home/yard

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

73.

Question - Not Required - Unfamiliar people entering home/yard

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

74.

Question - Not Required - Restraining/Hugging

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

75.

Question - Not Required - Grooming/Brushing

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

76.

Question - Not Required - Clipping nails/handling paws

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

77.

Question - Not Required - Pulling/grabbing collar

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

78.

Question - Not Required - Scolding/Punishing

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

79.

Question - Not Required - Excessive/rough petting

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

80.

Question - Not Required - Touching a certain body part

	No reaction
	Never tried
	Barks
	Shows teeth
	Grows
	Snaps
	Bites

81.

Question - Not Required - Please list any details to the previous section here.

82.

Question - Not Required - Does your dog display any possessive behaviors?

83.

Question - Not Required - If yes, what kind of resources does your dog guard?

	Food
	Bowls
	Bones
	Toys
	Stolen items
	Other

84.

Question - Not Required - Please describe any behavioral issues your dog has

(Maximum response 255 chars, approx. 5 rows of text)

85.

Question - Not Required - Please describe any major changes in your household recently , including the environment, health or routine of the people or pets that may have affected your dog's behavior?

(Maximum response 255 chars, approx. 5 rows of text)

HEALTH AND MEDICAL HISTORY

86.

Question - Not Required - Does your dog have recent or ongoing history of any of the following conditions? (check all that apply)

	Vomiting
	Diarrhea
	Not Eating
	Not Drinking
	Increased Drinking
	Increased Urination
	Urinary Tract Infections
	Bladder Stones
	Fractures/Broken Bone
	Limping
	Arthritis
	Hip Dysplasia
	Heart Murmur
	Heart Failure
	Heartworm Disease
	Coughing
	Kidney Disease
	Liver Disease
	Allergies
	Ear Infections
	Inflammatory Bowel
	Thyroid Condition
	Seizures
	Currently Pregnant
	Tumors (benign)
	Cancer (malignant)
	Chronic Eye Problems
	Blind
	Deaf
	Other
	My dog has not been diagnosed/treated for any medical conditions

87.

Question - Not Required - What medications, if any, is your dog currently on?

(Maximum response 255 chars, approx. 5 rows of text)

88.

Question - Not Required - Please provide any additional information on your pet's health:

(Maximum response 255 chars, approx. 5 rows of text)

89.

Question - Not Required - Has your dog ever been seen by a veterinarian?

90.

Question - Not Required - If so, when was the date of the last visit?

91.

Question - Not Required - Please provide name of your veterinarian, their practice, phone number, and location:

Please indicate your dog’s behaviors toward a groomer or veterinarian

92.

Question - Not Required - Examination

	Shows teeth/growls
	Snaps
	Bites
	Don't know
	None of these

93.

Question - Not Required - Restrain

	Shows teeth/growls
	Snaps
	Bites
	Don't know
	None of these

94.

Question - Not Required - Administer shots

	Shows teeth/growls
	Snaps
	Bites
	Don't know
	None of these

95.

Question - Not Required - Trim nails

	Shows teeth/growls
	Snaps
	Bites
	Don't know
	None of these

96.

Question - Not Required - Groom/Bath

	Shows teeth/growls
	Snaps
	Bites
	Don't know
	None of these

97.

Question - Not Required - Take blood

	Shows teeth/growls
	Snaps
	Bites
	Don't know
	None of these

98.

Question - Not Required - Does your dog need to be muzzled at the veterinarian?

99.

Question - Not Required - How much and how often does your dog eat?

100.

Question - Not Required - Do you feed your dog "people food?"

101.

Question - Not Required - Is there anything else you would like us to know about your dog?

(Maximum response 255 chars, approx. 5 rows of text)

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