Does your Animal Qualify to be on Our Waiting List?

MORONGO BASIN HUMANE SOCIETY
A. Dog and Household Information
Sex:
Spayed/Neutered?
1. What is your relationship to this dog?
4. What other animals did your dog live with?
Age Range
Male or Female
Age Range
Male or Female
Other: (List)
Male or Female
B. Typical Behavior
5. How does your dog usually react when you or another family member does the following?
6. How does your dog usually react when an unfamiliar person approaches or enters the yard or house?
7. How does your dog usually behave toward the following?

People your dog knows:
Men
Women
Children
Unfamiliar People:
Men
Women
Children
Familiar Animals:
Dogs
Cats
Unfamiliar Animals:
Dogs
Cats
8. Does your dog usually uncontrollably chase or attempt to chase any of the following?
9. Do you take your dog out to go to the bathroom?
10. Does your dog usually have "accidents" in the house?
11. Where does your dog spend most of his/her time?
12. How many hours per day is your dog left alone, without people, during the week?
12a. When your dog is left alone, is he/she...
12b. When left alone, does your dog usually show any of the following behaviors? (Please check all that apply.)
13. When you are home, does your dog usually show any of the following behaviors? (Please check all that apply.)
14. When your dog plays, does he/she typically... (Please check all that apply.)
15. What toys does your dog like? (Please check all that apply.)
16. What games does your dog like? (Please check all that apply.)
17. Is your dog scared of anything?
19. Is your dog allowed on furniture?
20. Where does your dog usually sleep overnight?
21. What commands does your dog know?
22. Has your dog attended any obedience training classes?
23. Has your dog ever been walked on the leash?
24. Does your dog have problems riding in the car?
25. Has your dog escaped your property 2 or more times in the last 6 months?
C. Aggressive Behavior
26. Is there any report of your dog ever inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)?
27. Has your dog ever attacked another dog resulting in severe injury or death to the other dog?
28. Has your dog ever attacked another domesticated animal species (cats or livestock but not "small pets" like hamsters, guinea pigs, etc.) resulting in severe injury or death to another domesticated animal?
29. Please check the appropriate box if your dog has ever shown any of the following aggressive behaviors:
Men
Women
Children
Dog
Other Domesticated Animal (cat, livestock)
29a. If a snap or bite to men or women was checked, did the snap or bite to adult take place while breaking up a dog fight or while a dog was in severe pain?
29b. If snap or bite to children was checked, did the snap or bite to a child take place while breaking up a dog fight or while a dog was in severe pain?
29d. If any aggressive behavior to men, women, or children was checked in the table above, please answer the following questions.
Was the aggressive behavior over food?
Men
Woman
Children
Was it over bones or rawhides or chews?
Men
Woman
Children
Was it over toys?
Men
Women
Children
Was it over stolen objects?
Men
Women
Children
Was it when the dog was disturbed while sleeping or resting?
Men
Women
Children
Was it when an adult or child handled the dog (brushing, handling feet, bathing, teeth brushing, ear cleaning, etc. but do NOT include reaction to vet or groomer)?
Men
Women
Children
Was it when an adult or child entered the house or yard?
Men
Women
Children
Was it when an adult or child approached or reached toward dog?
Men
Women
Children
D. Medical History
30. Does your dog see a veterinarian at least once a year?
If "yes", please specify the veterinarian name and contact info.
31. Has your dog ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer?
Examine (including heart and ears)
Restrain
Administer shots
Trim nails
Take blood
32. Does your dog have to be muzzled at the veterinarian?
33. Does your dog have any past or present medical conditions?
34. Is your dog currently on any medication or special diet?
35. What type of food does your dog eat?