NEW ENGLAND OLD ENGLISH SHEEPDOG RESCUE, INC. QUESTIONS FOR SOMEONE GIVING UP A DOG Date:_______________ Dog's name ________________________________ Age________ Present owner________________________________________________________ Address_______________________________________Email________________________ Home phone ______________________Work phone_______________________________ Children _______ how many ________ ages_______________________________ Other animals _____ how many _______ types______________________________________ Where did you get this OES? ___________________________________________________ Name of breeder/pet store_______________________________________________________ Address & phone of breeder/pet store_______________________________________________ How long have you owned the dog________________________________________ Reason for giving up____________________________________________________________ Sex ___ Spayed ______ Altered ______Tail _______  AKC records______________ Coat length (puppy cut, full length, shaved?)_________Last groomed? (date)_______ Groomer's name, address, phone___________________________________________________ Does dog need to be groomed now?______ matted_______ bath________ How does dog react to being groomed? ___________________________________ Food type_________________________________________________________ Feeding schedule____________________________________________________ Housebroken? _____  If yes, how long can dog left?__________________________ What signal does dog give?____________________________________________ Is dog on lead or left alone for "potty"?____________________________________ Any information about the previous owner will be appreciated in the space below. Previous owner's name______________________________________________________ Address____________________________________ Email___________________________ Phone (home)_____________________ (work)_____________________________ Children_____ how many ____________ ages______________________________ Other animals_____ how many__________ types ____________________________ Reason for giving up____________________________________________________________ Veterinarian ________________________________________________________ Address____________________________________________________________ Telephone __________________________________________________________ Commands dog responds to: Please answer either (always - sometimes - never) Sit___________ Down__________ Stay__________ Come__________ Heel______ Others______________________________________________________________ Is dog leash trained? ______if yes (good-fair-bad)_____________________________ Is your yard fenced? ____Is dog allowed to run loose? ____On leash at all times?______ Can you take dog for a walk off leash?_______________________________________ Comments____________________________________________________________ Health History Do you have all medical records with you?____________________________________ Your Veterinarian' name__________________________________________________ Address,phone________________________________________________________ Rabies ______________________ Tag #_________________ date______________ Distemper__________________________________________ date______________ Hepatitis___________________________________________ date______________ Parainfluenza _______________________________________ date______________ Parvovirus __________________________________________ date______________ Leptospirosis________________________________________ date______________ Bordetella__________________________________________ date______________ Corona____________________________________________ date______________ Fecal______________________________________________ date______________ Heartworm - date tested_______ last given ___________ type used________________ Weight__________ Please describe general health - including history of arthritis, colitis, skin problems, allergies, etc. Also, urine & bowel control:_____________________________ Typical day for the dog Please list what the dog is doing and with whom during the following times: 5:00am______________________________________________________________ 6:00am______________________________________________________________ 7:00am______________________________________________________________ 8:00am______________________________________________________________ 9:00am______________________________________________________________ 10:00am_____________________________________________________________ 11:00am_____________________________________________________________ 12:00 noon____________________________________________________________ 1:00pm______________________________________________________________ 2:00pm______________________________________________________________ 3:00pm______________________________________________________________ 4:00pm______________________________________________________________ 5:00pm______________________________________________________________ 6:00pm______________________________________________________________ 7:00pm______________________________________________________________ 8:00pm______________________________________________________________ 9:00pm______________________________________________________________ 10:00pm_____________________________________________________________ 11:00pm_____________________________________________________________ 12:00midnight________________________________________________________ 1:00 to 4 am__________________________________________________________ How many hours (maximum) can this OES stay alone? __________________________ How does dog behave when alone? ________________________________________ Is dog confined or allowed run of the house when alone? _________________________ Has dog been crate trained? ______________________________________________ Please circle one below. When left alone inside, is dog:    loose?    confined to one room?    crated?   in basement? Temperament Please check all that best describe the dog: aggressive_____ confident_____ dominate______ excitable______ hardheaded_____ laid-back______ nervous______ responsive______ sedate______ shy______ stubborn______ submissive______ timid______ hyper______ puppyish______ cooperative______ frantic______ Characteristics and Peculiarities The following is a list of dog behavior problems. Please list either (always - sometimes - never). If always or sometimes, please describe (when, where, why, etc.). Barking excessively - under what conditions?_____________________________ Begging__________________________________________________________ Biting - under what cicumstances?______________________________________ Growling________ when__________ Showing teeth ________ when___________ Car behavior when riding______________________________________________ Car chasing________________________________________________________ Car sickness_______________________________________________________ Cat chasing_________________________________________________________ Chewing - destructive__________________________________________________ Digging_____________________________________________________________ Dog fighting__________________________________________________________ Excessive wetting_____________________________________________________ Food guarding_______________________________________________________ Garbage ransacking___________________________________________________ Grooming___________________________________________________________ Herding____________________________________________________________ Housebreaking "mistakes"______________________________________________ Jealousy____________________________________________________________ How is dog with children, and can dog be trusted with infants and small children?______ ____________________________________________________________________ Protective?__________ Of whom? ________________________________________ How does dog react with strangers, other dogs and animals? _____________________ ___________________________________________________________________ Jumping fences_______________________________________________________ Jumping on furniture____________________________________________________ Jumping on people_____________________________________________________ Leash rejection_______________________________________________________ Pulling on leash_______________________________________________________ Mounting ____________________________________________________________ Nipping and mouthing___________________________________________________ Fear of confinement____________________________________________________ Fear of noises________________________________________________________ Fear of people________________________________________________________ Running away_________________________________________________________ Stealing food_________________________________________________________ Separation anxiety_____________________________________________________ Unique #1___________________________________________________________ Unique #2___________________________________________________________ Unique #3____________________________________________________________ How soon must you, or how desperate are you to give up the dog? Would you be willing to keep the dog until it is placed? ______________________________________________________ ___________________________________________________________________ ___________________________________________________________________     Before this dog can be placed in a new home, he must be groomed, updated on inoculations and have a current heartworm test. We also recommend that the dog be altered. If the owner is unable to do these things, we ask for a donation to help cover these expenses. We realize that every situation is different and our main concern is the welfare of the dog. Thank you for your cooperation.  I, (owner of said dog), have read, understood, and answered all of the above questions completely and honestly, making no misrepresentations concerning the temperament, health or behavior of the above named dog.   Date_____________________ Signed______________________________________________________ (owner)               ___________________________________________________ (witness) Send completed form to: Annie Raker,  49 Stonehedge Road,  Lincoln, MA 01773 781-259-8173    grannie.annie@neoesr.org