Salem – Dog Intake Salem Campus Intake - Dog Personality "*" indicates required fields General InformationDog's name* HiddenDog’s age or approximate age Dog's age in years*01234567891011121314151617181920212223242526272829+Use if the animal is over 1 years old, otherwise leave as 0Dog's age in months*01234567891011Use if the animal is above 3 months old, otherwise leave as 0Dog's age in weeks*0123456789101112Use only if the animal is below 3 months old, otherwise leave as 0Dog's breed* Dog's sex* Male Female Unsure Is your dog spayed/neutered?* Yes No Unsure Does your dog have a microchip?* Yes No Unsure How long have you owned this dog?* Where did you acquire this dog?* Oregon Humane Society – Portland Campus Oregon Humane Society – Salem Campus Other Shelter/ Rescue Organization Found as Stray Breeder/ Pet Store Private Party/ Courtesy Posting Family/ Relative Unintended Offspring Name of Other Shelter/Rescue Organization* Has your dog ever bitten anyone or any animal?* Yes No Did this incident break skin? Yes No Has your dog bitten anyone or any animal in the last 10 days?* Yes No Did this incident break skin? Yes No HistoryWhy are you rehoming your dog?*If we could help you resolve this issue would you be interested in keeping this dog?* What would you like new owners to know about this dog?*Has your dog ever been seen by a veterinarian?* Yes No When was the last time your dog went to the vet? What is the name of the clinic? How did the dog react to going to vet?* Is your pet currently taking any prescribed medications?* Yes No Please list all current medications Has your pet been diagnosed with a chronic medical condition that requires ongoing medical care?* Yes No Please describe the pet's medical condition Are there places on the dog's body he/she does not like being touched, brushed or petted? Yes No Where and what does the dog do? Home Life, Training & MannersHave you attended a 4-week (or longer) training course with your dog?* Yes No If yes, where did you take the pet for classes?* Oregon Humane Society Other How would you describe your dog most of the time? (check all that apply)* Affectionate Playful Lap dog Friendly with visitors Shy with family Shy with visitors Independent Very active Not very active Talkative Uses mouth/jumps up in play What words does your dog understand (check all that apply)? Sit Stay Down Come Leave it Drop Wait Heel Off Other What other words does the dog understand? What are your dog’s favorite things to do? i.e. favorite toys, treats and/or activities.* How does your dog do on leashed walks?* Can this dog be left alone in the house for 8 hours a day without issues?* Yes No If not, please explain what the animal does: Where was the dog when no human members of your family were at home?* Free roam of the house Confined particular room In garage or basement Crated Outside Did your dog ever escape the yard?* Yes No If yes, how? Housetraining: No accidents Urinates inside home Defecates inside home How often does the dog urinate inside the home? How often does the dog defecate inside the home? Is this dog possessive or protective?* Yes No If yes, when is your dog possessive or protective? Of food (towards people) Of toys (towards people) Of bedding (towards people) Of food (towards other animals) Of toys (towards other animals) Of bedding (towards other animals) Of property Of owner/family Other If you chose other, please explain: Does your dog live with any of the following (check all that apply): Large dogs Small dogs Cats Small animals Livestock Children What ages are the children? Would you recommend placing this dog in a home with other dogs?* Yes No What reason(s) would you recommend placing this dog in a home with other dogs?What reason(s) would you not recommend placing this dog in a home with other dogs?*Describe your dog’s play style with other dogs (check all that apply): Will play with all dogs Does not enjoy playing with other dogs at all Picky about the dogs they like Hangs out with other dogs rather than plays Plays rough with other dogs Chases or herds other dogs Barks constantly Prefers dogs that are gentle or indifferent Would you recommend placing this dog in a home with cats?* Yes No What reason(s) would you recommend placing this dog in a home with cats?What reason(s) would you not recommend placing this dog in a home with cats?Would you recommend this dog be around children regularly? Yes No What reason(s) would you recommend placing this dog in a home with children?What reason(s) would you not recommend placing this dog in a home with children?Please check all that frighten this dog: Babies or toddlers School-age children Teenagers Men Women Strangers/visitors People in uniform Veterinarian/groomer Loud voices/yelling Fireworks/loud noises Erratic or sudden movement Water Unpredictable children Broom/vacuum Riding in car Loud vehicles Has this dog done any of the following when interacting with adults in the home?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following when interacting with the children in the home?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following when interacting with visiting adults?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following when interacting with visiting children?* Barked at Growled Snapped Bitten None of the above Has the dog done any of the following with a vet or groomer?* Barked at Growled Snapped Bitten None of the above Has the dog done any of the following with pedestrians?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following with cars, bikes or skateboards?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following with resident dogs?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following with dogs outside of the home?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following with resident cats?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following with cats outside of the home?* Barked at Growled Snapped Bitten None of the above Has this dog done any of the following with wildlife and/or livestock?* Barked at Growled Snapped Bitten None of the above Your InformationYour name* First Last Please enter your address below* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your phone number*Email* The average daily cost for caring for each animal we receive is $150. We ask for a donation from each family using our services to help us in caring for your pet. Please indicate the amount you can comfortably afford to donate. Every dollar helps!*Please only include numbers. No symbols or letters. ex: I want to donate $150, I would put 150 in the boxIf you require language interpretation services, please select your preferred language below. Arabic Cantonese French German Italian Japanese Korean Mandarin Persian Portuguese Russian Spanish Vietnamese Other PhoneThis field is for validation purposes and should be left unchanged.
