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Email *
Today's Date *
Owner's Name(s): *
Owner's Phone # *
Owner's Street Address: *
Dog's Name: *
Breed: If a mix, list two predominant breeds in behavior: *
Dog's Sex: *
Is your dog spayed or neutered? *
Dogs Birthdate/Age: *
How Long have you owned your dog?: *
How old was your dog when acquired?: *
Has your dog had previous owners? If so, how many: *
If prior owners-Why was he/she given up:
Where did you get your dog? *
Did you meet your dog's biological parents or know anything about his/her littermates? *
Was temperament testing performed? *
Has  your dog attended any training classes? *
Has a dog trainer come to your home? *
Have you ever consulted with a behavior specialist? *
Which of the following best describes your dog's level of socialization with other dogs: *
What concerns do you have with your pet's behavior?  At what age did the problem begin?
Who (people) lives in the same home as your pet?  (Name, age, sex, relationship to you, average # of hours away from home per day, quality of relationship with your dog)
List ALL other pets that live in the same home as your pet.  (Names, species, breed, sex, spay/neutered?, age obtained, age now, was pet acquired before or after your dog?, quality of relationship with your dog)
What type of home do you live in?
Do you have a yard?  If so, what type of fence do you have?
Have there been changes in your household since acquiring your dog?  If so, how?
How many times is your dog walked on leash per day?
What is the average length of  walks?
How many times is your dog let out in the yard each day?
How long is your dog out for?
Does anyone go in the yard with him/her?
How many hours per day is your dog unsupervised outside?
Is there a dog door to go outside?
Where is your dog when home alone? (room, crate, loose, outside?)
Does your dog have access to the entire house at all times?
Where does your dog go when you have guests?
How do you play with your dog?
Does your dog ever urinate in the house?
Does your dog ever defecate in the house?
How does your dog behave when you prepare to leave the house?
How does your dog behave when you return home?
What does your dog eat?
How many meals is your dog offered per day?  Do they finish each meal?  Does someone have to be present for your dog to eat?
Where is the dog's food bowl?
If other animals eat at the same time, is it in the same room?
Does your dog have any food allergies or diet restrictions?
Is water available 24/7?
At what age was your dog neutered/spayed?
Has your dog ever been bred?
Are you planning to breed your dog?
Is your dog on heart worm and flea prevention?
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Please list any other medications your dog takes.
Does your dog have any medical problems?
What is your dog's relationship with other animals in your household?
What is your dog's response to new dogs?
Does your dog interact with other dogs outside the house on a regular basis?  When and where?
What does your dog think about cats or other small animals outside of your home?
Have there been any aggression (growling, showing teeth,  lunging, nipping, snapping, or biting) with any FAMILY MEMBER (who?) in the following situations:
-Petting or reaching for dog?
-Hugging or kissing dog?
-Bending over dog?
-Making eye contact with dog?
-Bathing, grooming, drying dog?
-Trimming nails?
-Disturbing dog when resting?
-Removing from furniture?
-Giving verbal or physical corrections?
-Approaching when dog has bone, treat, or chew toy?
-Putting on leash or collar?
-Grabbing collar?
-Lifting dog?
-Any other instance?
Has there been any aggression with NON-HOUSEHOLD members in the following situations?
-Petting or reaching for dog?
-Bending over dog?
-Making eye contact with dog?
-Entering your house or yard?
-Enter/exit any room in your home?
-Passing when dog is on leashed walk?
-Passing when dog is in car?
-Interacting with dog on leash?
-Putting on leash or collar?
-Grabbing collar?
-Any other instance?
Has your dog ever bitten a person?  How many times? Did any bites break the skin?
Does your dog act fearful in the following situations?  If so, how? (dilated pupils, trembles, cowers, tucks tail, hides, escapes, destructive, vocalizes, drool, defecate, urinate):
-Normal day at home with family member
-Dog is home alone
-Dog is home alone with another pet
-Dog and family members are home, but separated (ie different room, crate)
-Dog is home alone in crate
-Dog is at veterinary office
-Dog is at groomer
-Loud noises
-Flashes of light
Are there any other fearful stimuli? (ie men, umbrellas, vacuum)
How did you housetrain your dog?
Has your dog ever been crated?  Do you continue to use it?
What commands can your dog reliably perform?
Does your dog ever lick people, himself, or objects excessively?
Does your dog mount people, dogs, or objects?
If your dog sensitive to have certain body parts handled (ie ears or feet)?
Have you tried any of the following behavioral corrections, and how did your dog respond?
-Stare down
-Grab by jowls/scruff +/- shake
-Shake or throw a can
-Force down by leash
-Time out (where, when, how long?)
-Metal choke or pronged collar
-Water pistol/spray
-Halti collar or Gentle Leader
-Easy Walker Harness
-Bark or remote activated shock collar
-Invisible/electric fence
-Citronella spray collar
-Forced exposure to fearful stimuli
-Knee dog in check for jumping
-Hit or kick dog
-Growl at dog
-Lift dog by leash or collar
-Rub dog's nose/face into urine, feces, or area of destruction
-Tether to wall or floor with short lead
-Tether/tie out in yard
-Yell "no"
-"Alpha roll" (hold on back)
-"Dominance down" (hold on side, legs extended, head flat)
-Command to sit or lie down for extended period
-Agility or other sport activity
-Use of food or puzzle toys
-Praise for good behavior
-Food rewards for good behavior
-Kennel outdoors
-Command dog to "look" or "watch me"
-Increase play/exercise
-Clicker training
-Feed meals by hand
-Remove food bowl while eating
-Phermones (DAP, Comfort Zone)
-Anything else?
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