About You and Your Dog
Your First Name *
Your Last Name *
Address
Phone Number
E-mail *
Best Time to Reach You
Dog's Name *
List the names and ages of all family members living with your dog
If you have any other pets, please describe them
Is this your first dog?
yes no
How long have you had your dog?
Where did you get your dog?
Has you dog had any previous training?
yes no
If yes, please describe when, where, and for how long?
Name and phone number of your primary care Veterinarian
If your pet does not have a primary care Veterinarian, please explain
Does your dog receive an annual veterinary examination?
yes no
Month and Year of your dog's last visit to the Veterinarian
Is your dog current on his or her Rabies vaccine?
yes no
Describe any health or medical issues your dog may have
What brand of dog food do you feed your dog?
How often does your dog eat?
Describe your dog's activity level
Low Average High Excessive
Please describe how you play with your dog, and how often
Please describe how you exercise your dog, and how often
Where does your dog sleep?
Where does your dog spend most of his/her day?
Check all behaviors of concern
Excessive Barking Pulling on Leash Jumping Up Shy Difficult to Housetrain Destructive Chewing Stealing Items Uncontrollable Doesn't Come When Called Hyperactive Doesn't Listen Chases People/Children/Cars Overly Protective Fearful Aggressive towards people/children Aggressive towards other animals Nips at children Nips at adults Attacks other dogs or animals Submissive Urination Separation Anxiety other
If 'other' please describe
Out of all of the areas of concern you noted above, what are the three most troublesome?
What remedies have you tried for this/these problem(s) and how did they work?
What remedies are currently working well with your dog's behavioral issues?
If you got advice from other behavior consultants, what approach did they recommend?
How do you react when your dog does something you do not want or like?
Will your dog show teeth, growl, or snap in any of the following instances (check box if 'yes', leave blank for 'no')
if you touch his food dish while eating if you try to take away a toy, bone, or food in his mouth if you grab your dog if your dog steals something (food, sock, tissue) if you try to make him move from a favorite resting spot (bed, couch, etc) if you roll him on his back (to clip nails, or check for ticks for example)
Does your housetrained dog urinate inside?
yes no
if yes, please explain when, where and how frequent
Does your dog ever roll into his back and urinate when greeting you or other people?
yes no
Was your dog well socialized as a puppy?
yes no
If you take your dog to an unfamiliar place, is he fearful, hide, shake, try to escape?
yes no
Is there anything else we should know about you or your dog?
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