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Dog surrender form

To enable us to find the best possible home for your dog, please fill in all fields as completely and accurately as possible.
Did you originally get your dog from HSHV?
Did you originally get your dog from a shelter, rescue organization, or breeder?
Does your dog have a microchip? 
Has there been any changes in your household? 
Including yourself, how many people in each of the following age groups live in your house?
Male Member(s) of Household Quantity  
Age 0-3Age 4-9Age 10-17Age 18-29Age 30+
Female Member(s) of Household Quantity  
Age 0-3Age 4-9Age 10-17Age 18-29Age 30+
Has your dog interacted with other dogs at any of the following places in the past 6 months? 
**How would you describe your dog's behavior with children under 5? (Check all that apply.) 
Which of these behaviors occur when your dog is left alone? (Check all that apply.)
Has your dog ever injured him/herself doing any of these things?
When your dog is outside is s/he confined by 
Has your dog escaped your property more than 2 times in a 6 month period?
Were you able to correct the problem? 
Where does your dog sleep at night? (Check all that apply.) 
What form of exercise does your dog get? (Check all that apply.) 
Behavior and Training
Does your dog act afraid or nervous in certain situations? 
What behaviors have you noticed when your dog is nervous? (Check all that may apply.) 
Did it work?
**Can you easily take an object away from your dog? 
Is your dog house trained? 
Which of the following would you use to describe your dog? (Check all that apply.)
Have you used any of the following items/training tools with your dog? (Check all that apply.)
How long does it take your cat to acclimate to new situations or people?
How does your dog behave when being walked on a leash? 
Does your dog know any obedience commands?
Please indicate all known behavior traits. (Check all that apply.)
Medical background
**Does your dog ever growl, or try to bite at the vet office or groomer?
Does your dog need to be muzzled at the vet or groomer?
Does the muzzle help?
Is your dog sensitive about being touched?
Suppertime!
**What does your dog do when you approach him/her while eating, or if you try to take the food bowl away?
What does your dog do when a child approaches the food bowl while he or she is eating?
These are a few of my favorite things…
Please indicate your dog's favorite things. (Check all that apply.)