Dog Intake Questionnaire

We have a few questions that will help us assist you and your pet. Please be as detailed as possible when answering.

Date*

Your Name*

First Last

Preferred name

Pronouns

he/him, she/her, they/them, etc

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Phone*

Are you the owner of this dog?*

Yes
No

Please provide full name and contact information of the owner

General Information

Why are you surrendering your dog?*

What efforts have you taken to re-home your dog?*

What is your timeline for surrendering*

Less than 1 week
1-2 weeks
2 weeks - 1 month
Greater than 1 month

Seattle Humane is usually scheduling 1-2 weeks in advance. If you need immediate assistance, please contact your municipal shelter.

Dog's Name*

Age*

please include units - i.e. years

Breed(s)*

Color(s)*

Size*

Small (0-25 pounds)
Medium (25-50 pounds)
Large (50-75 pounds)
Extra-Large (75-100 pounds)

Sex*

Male
Female
Unsure

Spayed or neutered?*

Yes
No
Unsure

Is your dog microchipped?*

Yes
No
Unsure

Microchip number if known

History

How long have you had your dog?*

Please include units - i.e. years

Where did you get your dog?*

Ex: friend, craigslist, stray, breeder, pet store, etc

Has your dog seen a veterinarian?*

Yes
No
Unsure

Name of Vet or Clinic

We will contact your vet to obtain medical records. This helps us triage incoming animals and have a thorough picture of how to best serve you and your pet.

Phone Number of Vet or Clinic

Does your dog have any current medical conditions or illness?

Yes
No
Unsure

Please explain any medical conditions

What symptom(s) is your dog currently experiencing?

List any medications your dog is on

Include supplements as well as prescribed medications

Has your dog ever growled, lunged at, or barked at:*

Select all that apply

If other, please explain

How is your dog around unfamiliar people?*

How is your dog around unfamiliar dogs?*

Has your dog ever snapped at or bitten a person? Please select "yes" if your dog has done this, even if they did NOT break skin*

Yes
No

Has your dog ever snapped at, fought with, or bitten another animal? Please select yes if your dog has done this, even if they did NOT break skin*

Yes
No

Provide name and contact information of injured person or owner, including phone and address if known

What causes your dog to behave in this way? Please list all known triggers

Ex: cars, when people leave, when people try to pet, when my dog sees another dog, etc

How does your dog react when a trigger is present? Please be as descriptive as possible

Ex: lunges and barks, tries to chase, pins down and bites, gets fearful/crouches/hides, but will growl and bare teeth, etc

How do these incidents end?

Ex: I take dog away, we made a lot of noise to break up the fight, the dog leaves on his own, etc.

How long does your dog remain in an aroused or anxious state after the trigger occurs?

How have you been managing this behavior so far?

Resource Guarding

Does your dog growl, lunge, snap, or bite when you attempt to take away toys, food, treats, or other items the dog values?*

Yes
No
Unsure

What resources does your dog guard? Please list all known triggers

Ex: food, toys, space, people, etc.

How does your dog react when a trigger is present? Please be as descriptive as possible

Ex: lunges and barks, growls, moves away, eats faster, etc.

How do these incidents end?

Ex: I move away and he stops growling, I distract him with treats and then pick up the toy, etc.

How have you been managing this behavior so far?

Separation Anxiety

When leaving or left alone, does your dog pace, bark, cry, whine, pant, bite or chew doors/windows/furniture, or show other anxiety related behaviors?*

Yes
No
Unsure

How have you managed this behavior so far?

What does your dog do when left alone?*

Are they confined? If so, how?*

Ex: crate, downstairs with baby-gates, can move about the entire house, outdoor kennel, free roam of house and yard, etc.

How long can you leave them before they start showing signs of stress?

What behaviors do they show when stressed?

Tries to escape, claws doors, pants, paces, etc

Optional: Upload a photo of your dog

Max. file size: 50 MB.