Dog History Form "*" indicates required fields Owner's Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email Dog's Name Sex Male Female Dog's Age (Years)1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20+ yearsDog's Age (Months)1 month2 months3 months4 months5 months6 months7 months8 months9 months10 months11 monthsSpayed/Neutered?* Yes No How long have you had this dog? Please include years and months.What breed is this dog? Where did you get this dog? Capital Area Humane Society Friend/Relative Newspaper/Website Breeder Pet Store Other shelter (Please describe below) Found/Stray Other (Please describe below) If you adopted your dog from another shelter, what is the name of the shelter? Please describe the "other" place you got your dog? Why are you needing to re-home this dog? Moving Allergies Found/Stray Not getting along with other pets Behavior Issues (Please describe below) Other (Please describe below) Please explain behavior issues or "other" reason for surrender.How many people that live in your home are 0-3 years in age?012345678How many people that live in your home are 4-9 years in age?012345678How many people that live in your home are 10-15 years in age?012345678How many people that live in your home are 16-20 years in age?012345678How many people that live in your home are 21-29 years in age?012345678How many people that live in your home are 30-59 years in age?012345678How many people that live in your home are 60+ years in age?012345678What other pets did your dog live with? No other pets Dogs Cats Other (Please describe below) Please explain "other" pets. Behavior HistoryHow does your dog behave toward other dogs on a leash? Please check all that apply. Friendly Avoids Shows teeth Growls Lunges Barks Other Please explain "other" behaviors. How does your dog behave/interact with adults? Friendly Playful Cuddly Tolerates Hides Aggressive Please explain "other" behaviors. How does your dog behave/interact toward other familiar dogs in your household? Friendly Avoids Shows teeth Growls Lunges Barks Other Please explain "other" behaviors. How does your dog behave/interact toward cats in your household? Friendly Playful Cuddly Tolerates Hides Aggressive Never been around How does your dog behave/interact with young children? Friendly Playful Cuddly Tolerates Hides Aggressive Never been around How does your dog behave/interact with older children/teenagers? Friendly Playful Cuddly Tolerates Hides Aggressive Never been around How does your dog behave/interact at the vet's office? Friendly Playful Cuddly Tolerates Hides Aggressive Never visited Does your dog have any of the following behaviors? Please select all that apply. Escapes outside Gets on counters/tables Chews on electrical cords Sprays urine Fights with other cats/pets Scratches/bites people Scratches furniture Pees around the house Meows/vocalizes excessively Other (Please describe below) Please describe "other" behaviors.If you did discipline your dog, what was it disciplined for? Litter box accidents Eating plants Geting on counters/tables Bothering other pets Scratching/biting people Scratching furniture Other (Please describe below) Please describe "other" reason for discipline. What methods were used to discipline your dog? Verbal correction Put the cat outside Squirt bottle Timeout in crate/carrier Physical correction Ignore the behavior Did not discipline Other (Please describe below) Please describe "other" methods of discipline. Is your cat afraid of any of the following? Women Men Children Brushing Cat carrier Other animals Riding in the car Going to the vet Other (Please describe below) Please describe "other" things your cat is afraid of. What is your cat's behavior when it is afraid? Please select all that apply. Hides Shakes Bites Other (Please describe below) Please describe "other" behavior when your cat is afraid. Exercise and PlayWhat type of toys does your cat like to play with? Please select all that apply. Toy mice String Feathers Balls Other (Please describe below) What "other" things does your cat like to play with? What is your cat's play style? Gentle - no nipping/scratching Average - some nipping/scratching Rough - bites, but doesn't break skin/scratching Ambush/Stalking Other (Please describe below) Please describe "other" play style. What is your cat's activity level? Low energy Average Extremely Active Food/DietIs your dog currently on any medication or special diet? Yes (Please describe below) No Please describe medications and/or special diet for your dog?What type of food does your dog eat? Dry Wet What brand of dry/wet dog food does your dog prefer? How often do you feed your dog? Once daily Twice daily Free fed Medical HistoryName of veterinary clinic your dog has been to. Name of owner/person on the account at the veterinary clinic. First Last When was the last time your dog was seen by a veterinarian? Please list any type of flea prevention your dog has received. Date the last flea prevention was given. Does your dog have a microchip? Yes (Please list name of company below) No Unsure Name of the microchip company? Does your dog have any past or present medical conditions? Yes (Please describe below) No Describe past/present medical conditions.Please feel free to tell us any additional information.CAPTCHAFileMax. file size: 50 MB.
