A Pleasant Dog Behavior History Form
Please answer all of the questions herein to the best of your ability.
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
What pronouns do you use?
Phone *
Address, City, State, Zip Code *
Best Way to Contact You? *
Whom may we thank for referring you?
I understand that working with dogs may entail certain risks of personal injury to myself or my dog(s). I hereby acknowledge my voluntary and informed assumption of full responsibility and liability regarding any injuries that I or my dog may incur coincident to my participation with A Pleasant Dog. I hereby assume any and all risks associated therewith and expressly waive, release, discharge and hold harmless A Pleasant Dog, its members, agents, employees and assigns from and against any and all liability for loss, damage, injury, illness or claim of any nature whatsoever, however caused, arising out of, in association with, or related in any way to my involvement with its services.
Please accept our waiver of liability before submitting. *
Required
Who is your vet? *
What is your vets phone number?
Dog's Name: *
Dogs Date of Birth: *
MM
/
DD
/
YYYY
What is your dog's breed/sex? *
Is your dog spayed/neutered? *
Where did you acquire your dog (breeder, shelter, friend, etc.)? *
Did you have the opportunity to meet the parents? *
What is the main behavior, problem, or complaint? *
How serious do you feel this behavior is? *
How often does this behavior occur? *
What is the date of the most recent incident? *
MM
/
DD
/
YYYY
Please describe this incident in detail. *
What is the approximate date of the first occurrence? *
Please describe the first incident you remember. *
How old was your dog when he/she first began showing signs of this behavior? *
How long has this behavior been happening? *
Has there been any change in the frequency of the problem behavior or the way it is exhibited? *
When did this behavior become a serious concern? *
How do you discipline your dog for this problem or other misbehavior? *
What steps have you already taken to solve the problem? *
Does your dog have any other behavioral issues? *
What is your goal for this consultation? What would you like to accomplish? *
Please describe any medical problems that this dog has had/has currently: *
Is your dog currently on any medications or special diet? Please list all (including heartworm/flea medications) *
Please list all of the people living in the home, starting with yourself. Please provide the name, age, relationship and rate their relationship with the dog on a 1-10 scale. *
What type of area do you live in? (check all that apply) *
Required
What type of home do you live in (check all that apply) *
Required
Has the household changed since the dog was acquired? *
How many times have you moved with your dog since acquiring him/her? *
Does your dog have any previous owners? *
If you know, please write how many previous owners your dog had and their reasons for giving up the dog? *
Type(s) of food consumed? *
Brand of food: *
Supplements, snacks and treats: *
Have you recently changed your dog's diet? *
When is your dog fed (please list times) *
Where is your dog fed? *
Who feeds your dog? *
Please describe your dogs appetite: *
Please describe your dog's water intake: *
Does your dog ever steal food from counters? *
Does your dog ever steal food from the garbage?   *
Where does your dog sleep? *
Does your dog sleep all night? *
Where does your dog spend time during the day? *
Hours spent indoors: *
Hours spent outdoors: *
When outside are they: *
Is the dog allowed on the furniture inside? If so, what furniture are they allowed on? *
Are there any areas of the house that are off limits to the dog? *
What types of exercise does your dog get? How many hours per day? *
What is your dog's activity level in general? *
List the types of toys your dog has and indicate which toys are their favorite? *
Please list any other activities you engage in with your dog: *
List all animals in the household in the order they were acquired, including pets who have died within the last year. Include: Name, species, breed, sex, age, age at adoption, and indoor/outdoor: *
Please describe the relationships between the above pets and dog being evaluated: *
Do these pets groom the pet in question? *
Do these pets eat with the dog in question? *
These pets play with the dogs in question? *
Do these pets fight with the dog in question? *
Does your dog play with other pets outside the family? If so, please describe: *
Please describe other pertinent relationships: *
Has your dog ever exhibited any of the following TO ANOTHER DOG (check all that apply): *
Required
Is the dog house-trained? *
Has your dog ever been crate-trained? *
Has your dog attended obedience classes? *
What percent of the time does your dog obey the command "sit"? *
What percent of the time does your dog obey the command "down"? *
What percent of the time does your dog obey the command "stay"? *
What percent of the time does your dog obey the command "heel"? *
What percent of the time does your dog obey the command "come"? *
What tools have you used to train your dog? (select all that apply) *
Required
Does your dog behave when you leave home? *
How does your dog greet you when you return home (e.g., jump on you, run in circles, hide, wag tail, etc.)? *
Is this dog afraid of anything? Describe their fears: *
Does your dog like to be held by family members? *
Does your dog like to be groomed or brushed? *
Has your dog ever exhibited any of the following TO A PERSON OR CHILD? (check all that apply): *
Required
How does your dog react to children? *
Please check if your dog reacts when: (check all that apply) *
Required
The information you have provided will be used during your consultation will be used to develop a diagnosis and training/management plan. All information will be held in confidence but will be shared with your veterinarian and their team. *
Required
IF YOU DO NOT INCLUDE INFORMATION ABOUT PRIOR NIPS OR BITES IN THIS FORM, AND YOU ARE SCHEDULED FOR A PRIVATE TRAINING SESSION AT OUR NON-AGGRESSION RATE, IT IS POSSIBLE THAT THERE MAY BE A $50 TO $100 UPCHARGE AT THE TIME OF YOUR SESSION TO COMPENSATE FOR THE INCREASED DIFFICULTY OF THE SESSION. YOU MAY HAVE TO RESCHEDULE YOUR SESSION WITH A HEAD FACULTY TRAINER. Thank you for understanding! *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of A Pleasant Dog. Report Abuse
Google Forms