YOUR INFORMATION

First Name:

Last Name:

Address:

City:

State:

Zip:

Telephone:

Cell:

 

Mail:

 

How were you referred to us?

YOUR VETERINARIAN

First Name:

Last Name:

Hospital Name:

Address:

City:

State:

Telephone:

Fax:

E-mail:

YOUR DOG

1. What is your dog's name?

2. What is the breed (or mix of breeds) of your dog?

3. What type of coat does your dog have? (short, long, curly, wiry etc)

4. What color is your dog?

5. Is your dog a male or female?

Male Female

6. How old is your dog?

7. How much does your dog weigh?

8. Is your dog neutered (spayed or altered)?

Yes No

9. If yes, how old was your dog when he/she was neutered?

10. Why did you neuter your dog?

11. Where did you get your dog?

12. How old was your dog when you obtained him/her?

13. How long have you owned your dog?

14. Why did you choose this kind (breed) of dog?

15. Why did you choose your individual dog?

16. Does your dog have any medical problems?

Yes No

17. If yes, please list what they are?

18. When did they occur?

19. Is your dog being treated for any medical problem at this time?

Yes No

20. If yes, is your dog on any medication?

21. Do you know anything about your dog's parents or relatives?

Yes No

22. If yes, did they have any medical problems? (What were they?)

23. Did they have any behavioral problems? (What were they?)

YOUR HOUSEHOLD

1. Please list all of the people who live in your house with your dog and their ages.

2. Have you owned pets before? (If yes, what kind?)

3. When did you own the other pets?

4. Did you grow up with pets? (If yes, what kind?)

5. Did any of your other pets have behavior problems? (If yes, what kind?)

6. What happened to your other pets?

7. Please list all of the animals who live in your house: (Name, species (dog, cat, etc.), breed, sex, neuter status, age, when obtained, where obtained from)

8. What kind of home do you have? (house, apartment, town house)

9. How big is your home?

10. Is your dog allowed in all parts of your house? If not, where is your dog allowed?

PERSONAL DOG CARE

1. What do you feed your dog? (canned, dry, combination, table scraps)

2. What brand of food do you feed?

3. When do you feed your dog?(if meals, times/day, if free choice how often the bowl is filled)

4. Who feeds your dog?

5. Does your dog get treats? (If yes, what kind, how often, and when)

6. Do you feed your dog from the table?

Yes No

7. Does your dog beg for food?

Yes No

8. Where does your dog sleep at night?

9. Where does your dog stay when you are not at home?

10. Is your dog allowed on the furniture?

Yes No

MANAGEMENT

1. How many hours does your pet spend outside?

2. When and where outside does your dog run loose?

3. Do you have a yard? If yes, is it fenced?

4. If yes, what kind of fence do you have?

5. How tall is the fence?

6. Is your pet tied outside?

Yes No

7. If yes, what kind of tie-out?

8. Do you walk your pet on a leash? If yes, how many times per day?

9. How long is each walk?

10. If you walk your dog, what kind of walking device do you use?

11.Does your dog pull on the leash?

Yes No

12. Does your dog receive regular exercise?

Yes No

13. If yes, what kind? How many times per day or week?

14. How long is each session?

15. Do you play with your dog?

Yes No

16. If yes, how do you play with your dog? (ball, frisbee, wrestle, etc.)

17. How many times per day or week?

18. How long is each session?

OBEDIENCE TRAINING

1. Has your dog received any formal obedience training?

Yes No

2. If yes, why did you decide to obedience train your dog?

3. If yes, did you go to group classes? Or did you have private sessions with your trainer?

4. How many lessons did you and your dog attend?

5. Which family members went to the training classes?

6. How did your dog do in the classes?

7. What commands does your dog know?

8. Will he/she do these commands if you do not have a food treat?

Yes No

9. Did you like your trainer? If yes, what is the name of your trainer?

10. Where is he/she located?

11. What is his/her telephone number?

12. Did your trainer recommend food as rewards during training?

Yes No

13. Did your trainer recommend that you use a choke chain, pinch collar or head collar?

Yes No

14. If you are using a head collar, what brand?

15. Did your trainer recommend that you use a shock collar? If yes, when were you told to shock your dog?

16. Did your trainer recommend Clicker training?

Yes No

17. If you didn't take your dog to formal obedience classes, did you teach your dog commands? If yes, which commands?

18. Will your dog do these commands if you do not have food treats?

Yes No

19. Have you ever taken another dog to obedience classes?

Yes No

20. Does your dog have any AKC or UKC titles? (Champion, CD, AD etc.)

THE PROBLEM

1. What is your dog doing that is problem to you?

2. Does your dog have any other behavior problems?

3. What happened that made you decide to seek help?

4. When was it?

5. What happened before the incident?

6. How did you respond after the incident?

7. How did your dog respond?

THE HISTORY/DEVELOPMENT OF THE PROBLEM AND CORRECTIONS ATTEMPTED

1. How long have you and your dog had this problem?

2. When was the first time you noticed that your dog had the problem?

3. How old was your dog when you noticed that your dog had this problem?

4. Describe in detail the very first episode of the problem.

5. When was it?

6. What time of day?

7. What happened before?

8. What did you do after it occurred?

9. What did your dog do after the incident?

10. Describe in detail another early episode of the problem.

11. When was it? What time of day?

12. What happened before?

13. What did you do after it occurred?

14. What did your dog do?

15. Tell us everything that you have done to try to correct the problem you are having. "Include the dates of all attempted corrections, how long you tried and how your dog responded" (no better, somewhat better, much better).

16. Has your dog been on any medications for the behavior problem? If yes, what types? When? For how long?

DETAILED DESCRIPTIONS OF RECENT INCIDENTS

Describe in detail the most recent episode of the problem:

1. When was it? What time of day?

2. What happened before?

3. What did you do after the episode?

4. How did your dog respond?

Describe in detail the next to last episode of the problem:

5. When was it? What time of day?

6. What happened before the incident?

7. What did you do after the incident?

8. How did your dog respond?

Describe in detail the third to last episode of the problem:

9. When was it? What time of day?

10. What happened before the incident?

11. What did you do after the incident?

12. How did your dog respond?

13. How often does the problem occur? (times per day, per week, per month)

14. Does the problem happen more often now than when it started? If yes, please describe.

15. Was the increase gradual or sudden?

16. Is the problem worse in severity/intensity since it started? If yes, please describe.

17. How often do your dog's other problems occur? (times per day, week or month)Please list problem and frequency

18. Does the problem happen more often that when it started? If yes, please describe.

19. Was the increase gradual or sudden?

20. Is the problem worse in severity/intensity since it started? If yes, please describe.

AGGRESSION SCREEN

1. Has your dog ever bitten a person?

Yes No

2. If yes, did the bite break the skin?

Yes No

3. If yes, was the bite reported?

Yes No

4. If yes, was your dog quarantined?

Yes No

5. If yes, did the bite require medical treatment?

Yes No

6. If yes, what kind? (for example, tetanus shot, antibiotics, stitches)

7. Has your dog ever bitten another animal?

Yes No

8. If yes, what kind of animal?

9. If yes, did the bite break the skin?

Yes No

10. If yes, was the bite reported?

Yes No

11. If yes, was your dog quarantined?

Yes No

12. If yes, did the bite require medical treatment?

Yes No

13. If yes, what kind? (for example veterinary visit, antibiotics, stitches)

Describe what your dog does if you do the following things? (Please indicate if you or your family have never done these things. We are especially interested if your dog shows his/her teeth, growls, barks, snaps or bites. But also if your dog doesn't care.)

1. Pet your dog while he/she is eating dog food.

2. Touch your dog's bowl while he/she is eating dog food.

3. Pet your dog while he/she is eating delicious food in the bowl (table scraps).

4. Touch your dog's bowl while he/she is eating delicious food.

5. Pet your dog while he/she is eating a real meat bone.

6. Touch the real meat bone.

7. Pet your dog while he/she is eating a rawhide or pig's ear.

8. Touch the rawhide or pig's ear.

9. Try to take away a stolen piece of food. (for example from the table or counter)

10. Try to take away a stolen non-food item. (for example piece of clothing)

11. Try to take away your dog's favorite toy.

12. Reach for a piece of food which has fallen from a table or counter.

13. Pet your dog while he/she is sleeping.

14. Move your dog while he/she is sleeping.

15. Pet your dog while he/she is resting in a comfortable place (couch).

16. Move your dog while he/she is resting in a comfortable place (couch).

17. Approach your dog while he/she is in the crate (cage).

18. You hold your dog back if he/she tries to run out the door.

19. Pull on your dog's collar.

20. Pull on your dog's collar while he/she is barking at something at the door.

21. Lift your dog.

22. Untangle your dog (as in the leash).

23. Put your dog's collar on.

24. Take your dog's collar off.

25. Put your dog's leash on.

26. Take your dog's leash off.

27. Put your dog's harness on.

28. Take your dog's harness off.

29. Put your dog's coat/sweater on.

30. Take your dog's coat/sweater off.

31. Brush your dog.

32. Trim your dog's nails.

33. Towel dry your dog when wet.

34. Wipe your dog's feet.

35. Wipe your dog's face, eyes or mouth.

36. Put medication in your dog's ears.

37. Put medication in your dog's eyes.

38. Cause a little pain (take a tick off or step on your dog's foot or tail).

39. Pet your dog.

40. Hug your dog.

41. Reach over your dog while lying down.

42. Push your dog into a sit.

43. Push/pull your dog to lie down.

44. If your dog is resting with one person and another person approaches. (indicate who the people are)

45. When two family members hug.

46. When you reprimand your dog in a loud voice.

47. When you reprimand your dog by raising a hand or shaking a finger.

48. When you hold your dog's muzzle.

49. When you shake your dog by the skin on the back of the neck.

50. When you hit your dog. (where do you hit your dog?)

51. When you jerk on your dog's leash.

52. When you stare at your dog.

53. When your veterinarian examines your dog.

54. When your veterinarian restrains your dog.

.

55. When your veterinarian gives your dog a shot

56. When a groomer grooms your dog.

57. When a stranger walks past your home or yard.

58. When a stranger enters your home or yard.

59. When a stranger walks past your car.

60. When a stranger enters your car.

61. When a stranger approaches you on a walk.

62. When a stranger pets your dog on a walk.

63. When a service person fills your car with gas.

64. When you go to a toll booth.

65. When your dog sees unfamiliar children.

66. When your dog is approached by unfamiliar children.

67. When you are approached by unfamiliar children.

68. When your dog is petted by unfamiliar children.

69. When your dog sees unfamiliar dogs.

70. When your dog is approached by unfamiliar dogs.

71. When an unfamiliar dog enters your home.

72. When an unfamiliar dog enters your yard.

73. When a jogger runs past your dog.

74. When a roller blader skates past your dog.

75. When a skateboarder skates past your dog.

ATTACHMENT

On a scale of 1 to 10, How serious is each problem to you and to each family member?
1 being not at all serious and 10 being the most serious:

1. Main problem:

2. Other problems:

Have you considered getting rid of your cat? Why have you not done so? (this question does not mean we are recommending this)

Have you considered putting your cat to sleep? (this question does not mean we are recommending this) Why have you not done so?

If you have any question or for more information on the dog classes, please call us and we'll take your
information by phone (781) 862-5060.
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