Dog Surrender – Larimer Humane Society

Lifestyle and Home Life

Was this dog (check all that apply)

Indoors except to potty
Outdoors during the day, in at night
Outside 24 hours
In and out throughout the day

This dog sleeps (check all that apply)

Inside, on the floor
Inside, on a dog bed
Inside, on a chair or sofa
Inside, in bed with adults
Inside, in bed with children
In a crate
In a garage or barn
Outside, in a dog house
Outside, on ground or under porch

Is this dog housebroken? (check all that apply)

Yes, completely
No, has frequent accidents
Mostly, has occaional accidents
Only has accidents while left alone for long periods
Accidents are urine only
Accidents are bowel movements only

While outside, my dog is: (check all that apply)

No confinement, allowed to run loose
6' - 8' privacy fence
3' - 4' chain link fence
Fenced run
Confined in garage
Tethered by chain or cable

Have you had any problems keeping this dog confined? (check all that apply)

No, stays in yard
Yes, jumps fence
Yes, digs to get out
Other

Please explain:

Is this dog ever crated? (check all that apply)

No
Yes, for car rides
Yes, when left alone
Yes, during the day
Yes, overnight

What kinds of exercise did this dog receive? (check all that apply)

Daily walk, on lead
Placed on cable or run outside
Walked 1-3 times per week, on lead
Put out in fenced yard
No regular exercise period
Taken to off-leash park or the country to run loose

Has this dog regularly been around children?

No
Yes

How old were the children?

How does this dog behave around adults?

Describe how this dog behaves when people come to visit. (check all that apply)

Please explain:

How does this dog behave around other dogs? (check all that apply)

Never been around other dogs
Friendly, no fighting
Fight over certain situations or possessions
This dog picked on other dogs
Stiff, nervous
Other dogs picked on this dog
Didn't really care, avoided other dogs
Did not get along at all, constantly fought
Other

Please explain:

How does this dog behave around cats? (check all that apply)

Never been around other cats
Friendly, no fighting
Fight over certain situations or possessions
This dog picked on other cats
Stiff, nervous
Cats picked on this dog
Didn't really care, avoided other cats
Did not get along at all, constantly fought
otherd

Please Explain

My dog knows: (check all that apply)

Sit
Stay
Come
Down
Heel
Shake
Fetch
Other

Please explain:

How does this dog behave on leash? (check all that apply)

Has experience, walks calmly, no pulling
Pulls occasionally, but mostly does well
Pulls constantly
Fights the leash, bites and struggles
No experience on leash

What is your dog afraid of? (check all that apply)

Please explain:

How is this dog disciplined? (check all that apply)

Yelling, scolding
Body gestures, arms waving, etc.
Locked away for time-out
Thrown outside
Physically taken over to mess, nose rubbed in it
Discipline handed out when the mess is found
Ignore it, clean up mess, try to catch the dog in the act to teach corrective behavior
Physical contact, hitting, kicking

Does this dog have any of the following behaviors that you consider a problem? (check all that apply)

Please explain:

If you checked any of the above, please elaborate:

Has this dog ever been aggressive towards people or animals? (check all that apply)

Yes, has attacked or bit people
Yes, has attacked or bit other dogs
Yes, has attacked or bit other animals
Yes, has growled at or lunged at people
Yes, has growled at or lunged at dogs
Yes, has growled at or lunged at other animals
No, has shown no aggression towards animals or people

Dog Surrender Form

Step 1 of 8

General History

Owner Information

General History

Medical History

Dietary Habits

Personality Profile

Lifestyle and Home Life

Additional Information