Canine Behavior History Form

Canine Behavior History Form

Blue Prints Training and Socialization Center reserves the right to refuse any dog for services
Date

Month Day Year
Date
Owner/Home Information
Owner's Name *

First Name Last Name
Second Owner's Name

First Name Last Name
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *

Area Code Phone Number
Email *
example@example.com
Please list all people who live in the household in the following format. Please list yourself first. *
Are there any other dogs in the house? *

Yes No
Please list all other dogs in the home:
Are there any cats in the household? *

Yes No
If yes, how many?
What type of area do you live in? *

City/Town Suburbs/Neighborhood Rural
Please describe the house you live in:
ex: ranch style, two-level, farmhouse, etc.
Have there been any major changes in your home since you've had your dog?
ex: moving, remodel, new/loss of animal, family member moving in, etc.
Are you a first time dog owner?

Yes No
Dog Information
Dog's Name *
How old is your dog?
years/months
When is your dog's birthday? (mm/dd/yy) *
Please give an approximate birthday if unsure of the exact date
Sex of the dog: *

Male Female
Is your dog spayed/neutered? *

Yes No
Approximate weight:
lbs.
Breed of the dog: *
if mixed, list the dominant breed
Was the breed chosen specifically? If so, why?
Age of your dog when acquired:
Where did you acquire your dog?
Has any owned your dog before you? If so, how many owners?
Is your dog crated trained? *

Yes No
What made you decide to get a dog?
Diet and Medical Information

Please fill this section out completely, putting "N/A" in sections that don't apply to your dog
What veterinary clinic do you currently use? *
Please list any medical problems your dog is current experiencing:
Please list any medications your dog is currently prescribed:
Please include dosage
Does your dog have any dietary restrictions? If yes, please describe:
What brand of food do you feed your dog? *
How much do you feed them and how often? *
Any noticeable changes in appetite recently?
Who feeds the dog? *
Where is your dog fed and what do they eat out of? *
Your dog's daily routines

Please answer these questions completely based on your dog's average day
On average, how many hours is your dog left alone during the day? *
Where does your dog stay during these hours? *
When your dog is outside, are they.. *

Tied out Fenced in Off leash Walked on leash
Where is your dog when guests come over? *
On average, how many times do you walk your dog a week and for how long each time? *
What are your dog's favorite toys/activities? *
How often do you play with your dog? *
Where does your dog sleep at night? *
Have you noticed any changes in their sleeping habits?
Generally, what is your dog's activity level? *

Low Average High Excessive
Training History and Information
Was your dog professionally trained? *

Yes No
If yes, where and when?
How old was your dog when this training occurred?
Did you train the dog yourself?

Yes No
Do you feel the training you completed was successful? *

Yes! There is just a new behavior that arose Kind of, just a few behaviors that need to be sharpened Not really... Not at all!
Is your dog house trained? *

Yes No
Please describe any basic behaviors and/or tricks your dog knows: *
Who in the family is the primary trainer? *
Does your dog listen well to the rest of the family? Please be specific: *
Does your dog jump on others without permission? *

Yes Sometimes No
Does your dog ever bark at you? *

Yes Sometimes No
If yes, when does that happen?
Does your dog bark at other things? *

Yes Sometimes No
If yes, please describe:
What is the main concern/issue you are currently having with your dog? *
How long has this problem been occurring?
How often does this problem occur?
Has this problem escalated in frequency and/or intensity since the start?
Was there a main episode that concerns you the most? If yes, please explain:
Any other concerns or significant incidents?
What have you done to correct these problems so far? *
How do you discipline your dog when they misbehave? *
What is your goal for training? Where would you like your dog to be by the end? *
Aggression Information

Please fill this chart out completely! If the reaction is something other than what is listed (such as excited/friendly) please check "no reaction". Please check "bark" even if the bark is from excitement and not aggression.
Has your dog ever bitten a person? *

Yes, broke skin Yes, did not break skin No
If so, was it reported?

Yes No
How many times has this happened?
How severe were the injuries to the person?
Has your dog ever bitten another animal? *

Yes No
If so, was it reported?

Yes No
If yes, what kind of animal?
Dog, rabbit, cat, etc.
How many times has this happened?
How severe were the injuries to the animal?
Did your dog bite as a puppy? *

Yes No Unsure

Please indicate your dog's reactions in the following situations:

No reaction

Excited behavior

Lift lip/Snarl

Growl

Bark

Snap/Bite

Not attempted

Take food away while the dog is eating

Take away human food whether given or stolen

Take away bone while chewing

Take away toy while playing

Take away item dog has stolen and ran away with

Lift the dog

Kiss the dog

Hug the dog

Reach over the dog

Stare at the dog

Approach dog on bed or sofa

Push dog off bed or sofa

Disturb dog while resting

Put leash or collar on dog

Take leash or collar off dog

Leash/collar correction

Trim nails

Medicate eyes/ears

Accidentally cause pain (i.e. step on tail)

Physically punish (i.e. scruff, shake, slap)

Verbally punish/Yell

Visually punish or threat (i.e. wagging your finger)

Push dog in to another position (i.e. sit)

Dog is sitting with someone and another person approaches

Stranger passes by your home

Stranger approaches your home

Adult stranger enters home

Child stranger enters home

Adult your dog is familiar with enters home

Child your dog is familiar with enters home

Dog is on leash and sees stranger

Dog is on leash and approached by adult

Dog is on leash and is approached by a child

Dog is on leash and passes by another dog

Dog is on leash and is approached by another dog

If you have a selection/selections from the list above that you'd like to give more details on, please do:
How do you feel about your situation as it is now? *

Not serious, I am only curious about a few small things Not too serious, but I would like to change the problem The problem is serious but is livable if it remains unchanged The problem is very serious, and I would like to change it but will keep the dog if nothing changes The problem is very serious and if it remains unchanged, I will have to give up/rehome the dog
What form of training do you prefer? (final decision is at the discretion of the trainer) *

Private Training In-Home (60-90 min per session) Private Training in Blue Prints Facility (60-90 min per session) Training Package (drop off dog up to 4 hours, 2-3x a week) Unsure
What is your general availability for training?
Ex: Weekdays after 5pm and weekends
Contract Information
General Policies for Training:

I understand that the trainer and the training facility within Nottingham Plaza, Syracuse, New York, are not responsible for any further training or behavioral problems that may occur at any given date.

I understand that any training package purchases will expire in 90 days from original purchase date. Any classes purchased and transferred to private sessions expire 90 days from the original purchase date of the class.

I also have thoroughly read and understand the following:
- Payment is due no longer than 1 week after services rendered.
- It is an owner’s responsibility to continue the exercises described by the trainer at the end of a completed lesson to see consistent results.
- Please give 24 hours’ notice if cancelling a scheduled lesson.
- One make-up session is available per group class with a valid reason for missing that week’s session. All class dates are preset, and owners are expected to be on time and present for each scheduled session.
- Children 10 and under must be accompanied by an adult during training sessions.
By signing below, I acknowledge that I have read and agree to all the terms and conditions listed under the General Policies set forth by Blue Prints Training and Socialization Center.
Is your dog's picture allowed on our social media site? *

Yes No
Signature

Clear
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Canine Behavior History Form

Owner/Home Information

Dog Information

Diet and Medical Information

Your dog's daily routines

Training History and Information

Aggression Information

Contract Information