Pre-visit questionnaire for dogs

1
Phone Number
Area Code
Phone Number
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email
example@example.com
4
Your Name
First Name
Last Name
5
Date of your appointment
Date
Year
Month
Day
6
Pet Name
7
Age or DOB
8
Breed
9
Sex
Male
Male neutered
Female
Female speyed
10
If your dog is neutered
How old was your dog neutered?
Please describe any changes after neutering
11
Your regular vet
12
Regular dog trainer
13
Insurance provider
14
What type of food do you feed your dog? Please list all the regular food types, eg dry food, tin food, dog roll, raw meat, home cooked food (please list all ingredients) etc.
Huge
Large
Normal
Small
Ok
Ok
15
Describe your dog's interest/appetite in the regular diet.
Voracious
Good
Average
Poor
Variable
16
If you could give any type of treats what would be your dog's favorite reward? List top 5:
17
Other than food, what other rewards (e.g. toy, affection) would be most enticing to your dog? List top 5:
18
List any supplements or additives that you offered or planning to offer.
19
List out all medication
20
List out all allergy
21
Where did you obtain your pet?eg name of shelter, name of breeder, a friend, Gumtree etc.
22
Age obtained?
23
Weaning age
24
Did you meet your pet's parents and littermates? Please briefly describe their behaviour and any other information you noticed.
Huge
Large
Normal
Small
Ok
Ok
25
For what reason did you obtain this pet? Check all that apply.
Companion for family
Companion for other pet(s)
Work
Agility
Breeding
Protection
Other
26
Describe your dog's personality (check all that apply).
Friendly
Confident
Calm
Timid
Fearful
Aggressive
Noisy/ vocal
Quiet
Excitable
Hyperactive
Stubborn
Depressed
Other
27
Was there any behaviour concerns in the early months after your obtained the pet?
YESNO
28
If the above answer was yes, please describe the concerns/ issues.
Huge
Large
Normal
Small
Ok
Ok
29
Please provide details of ALL members in the household.
30
Please provide details of
Name
Age
Occupation
Household member
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Household member
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Household member
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Household member
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Household member
Household member
Household member
Household member
Name
Row 0, Column 0
Age
Row 0, Column 1
Occupation
Row 0, Column 2
Name
Row 1, Column 0
Age
Row 1, Column 1
Occupation
Row 1, Column 2
Name
Row 2, Column 0
Age
Row 2, Column 1
Occupation
Row 2, Column 2
Name
Row 3, Column 0
Age
Row 3, Column 1
Occupation
Row 3, Column 2
1 of 4
31
Describe how your pet gets along with each family member including any problems.
Huge
Large
Normal
Small
Ok
Ok
32
Please provide details of
Name
Age
Breed
Sex
Neutered
Pet
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Male
Female
Row 0, Column 3
Row 0, Column 4
Pet
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Male
Female
Row 1, Column 3
Row 1, Column 4
Pet
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Male
Female
Row 2, Column 3
Row 2, Column 4
Pet
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Male
Female
Row 3, Column 3
Row 3, Column 4
Pet
Pet
Pet
Pet
Name
Row 0, Column 0
Age
Row 0, Column 1
Breed
Row 0, Column 2
Sex
Male
Female
Row 0, Column 3
Neutered
Row 0, Column 4
Name
Row 1, Column 0
Age
Row 1, Column 1
Breed
Row 1, Column 2
Sex
Male
Female
Row 1, Column 3
Neutered
Row 1, Column 4
Name
Row 2, Column 0
Age
Row 2, Column 1
Breed
Row 2, Column 2
Sex
Male
Female
Row 2, Column 3
Neutered
Row 2, Column 4
Name
Row 3, Column 0
Age
Row 3, Column 1
Breed
Row 3, Column 2
Sex
Male
Female
Row 3, Column 3
Neutered
Row 3, Column 4
1 of 4
33
Please provide details of ALL pets in the household.
34
Describe how your dog gets along with each pet including any problems.
Huge
Large
Normal
Small
Ok
Ok
35
Describe the usual daily schedule for you and your dog.What's your dog's typical day looks like?
Huge
Large
Normal
Small
Ok
Ok
36
Describe the type of exercise / play sessions you offer including how often, how long and with whom.
Huge
Large
Normal
Small
Ok
Ok
37
Do you offer enrichment toys? If yes, what type? How does your pet enjoy it?
38
Describe chewing and exploration.
Little or no interest
Mostly directed to own toys and chews
Mild household damage
Moderate household damage
Severe household damage
39
If there are damages, describe when, how often, and targets.
Huge
Large
Normal
Small
Ok
Ok
40
*Not required for home visit client. Please provide your home floor plan if possible, and upload some photos of your home, including the dog's resting area, area your dog spends most time at, and the outside.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
41
Where is your dog's preferred sleeping spot during the day?
42
Where does the dog sleep at night?
43
Time your pet goes to bed and wakes up
44
Sleep quality: does you pet sleep well, or moves around often during the night?
45
Have you used a crate or pen to confine? If yes, describe the crate and its location. How often and when do you use it?
Huge
Large
Normal
Small
Ok
Ok
46
Has your dog had obedience training, professional training or professional behavioural assistance? Please provide the name or business name of the trainer or club.
47
Any tools used for the training mentioned above?
Clicker
Slip lead
Head halter
Front control harness
Choke collar
Prong collar
VIbration only collar
Citronella collar
Electric collar
Spray bottle
Tool that make noises (chain, keys, ultrasonic)
Other
48
Have you used a trainer, veterinarian or behaviour specialist for the problem for which you are seeking help today?
Huge
Large
Normal
Small
Ok
Ok
49
What books / DVD / TV shows / YouTube channel have you seen and implemented?
Huge
Large
Normal
Small
Ok
Ok
50
What type of training has been the most successful?
Huge
Large
Normal
Small
Ok
Ok
51
List family member(s) with most control.
52
List family member(s) with least control.
53
How does your dog respond to cues at home?Excellent = in all environments; Good = except for major distractions; Fair = does not listen if distractions; Poor = does not listen without distractions; Never = never taught or performed
Excellent
Good
Fair
Poor
Never
Sit
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Down
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Come (indoor)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Come (in yard)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Come (in public)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Walk on loose leash
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Give (drop toy)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Give (drop stolen item)
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Go to bed/mat/kennel
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Watch "look at me"
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Sit
Down
Come (indoor)
Come (in yard)
Come (in public)
Walk on loose leash
Give (drop toy)
Give (drop stolen item)
Go to bed/mat/kennel
Watch "look at me"
Excellent
Row 0, Column 0
Good
Row 0, Column 1
Fair
Row 0, Column 2
Poor
Row 0, Column 3
Never
Row 0, Column 4
Excellent
Row 1, Column 0
Good
Row 1, Column 1
Fair
Row 1, Column 2
Poor
Row 1, Column 3
Never
Row 1, Column 4
Excellent
Row 2, Column 0
Good
Row 2, Column 1
Fair
Row 2, Column 2
Poor
Row 2, Column 3
Never
Row 2, Column 4
Excellent
Row 3, Column 0
Good
Row 3, Column 1
Fair
Row 3, Column 2
Poor
Row 3, Column 3
Never
Row 3, Column 4
Excellent
Row 4, Column 0
Good
Row 4, Column 1
Fair
Row 4, Column 2
Poor
Row 4, Column 3
Never
Row 4, Column 4
Excellent
Row 5, Column 0
Good
Row 5, Column 1
Fair
Row 5, Column 2
Poor
Row 5, Column 3
Never
Row 5, Column 4
Excellent
Row 6, Column 0
Good
Row 6, Column 1
Fair
Row 6, Column 2
Poor
Row 6, Column 3
Never
Row 6, Column 4
Excellent
Row 7, Column 0
Good
Row 7, Column 1
Fair
Row 7, Column 2
Poor
Row 7, Column 3
Never
Row 7, Column 4
Excellent
Row 8, Column 0
Good
Row 8, Column 1
Fair
Row 8, Column 2
Poor
Row 8, Column 3
Never
Row 8, Column 4
Excellent
Row 9, Column 0
Good
Row 9, Column 1
Fair
Row 9, Column 2
Poor
Row 9, Column 3
Never
Row 9, Column 4
1 of 10
54
Please indicate if you have used the following training techniques. If you did, how often, and how effective it was
Never
Tried
Used often
Improves
Worsen
Verbal punishment (no, stop)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Physical punishment (rub nose, hit)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Pin or roll over
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Shake keys/chain
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Ultrasonic alarm
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Spray water/air/citronella
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Repellent
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Time out
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Remote electric collar
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Remote citronella collar
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Bark collar
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Containment collar
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Verbal praise
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Food/treat reward
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Toy reward
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
Verbal punishment (no, stop)
Physical punishment (rub nose, hit)
Pin or roll over
Shake keys/chain
Ultrasonic alarm
Spray water/air/citronella
Repellent
Time out
Remote electric collar
Remote citronella collar
Bark collar
Containment collar
Verbal praise
Food/treat reward
Toy reward
Never
Row 0, Column 0
Tried
Row 0, Column 1
Used often
Row 0, Column 2
Improves
Row 0, Column 3
Worsen
Row 0, Column 4
Never
Row 1, Column 0
Tried
Row 1, Column 1
Used often
Row 1, Column 2
Improves
Row 1, Column 3
Worsen
Row 1, Column 4
Never
Row 2, Column 0
Tried
Row 2, Column 1
Used often
Row 2, Column 2
Improves
Row 2, Column 3
Worsen
Row 2, Column 4
Never
Row 3, Column 0
Tried
Row 3, Column 1
Used often
Row 3, Column 2
Improves
Row 3, Column 3
Worsen
Row 3, Column 4
Never
Row 4, Column 0
Tried
Row 4, Column 1
Used often
Row 4, Column 2
Improves
Row 4, Column 3
Worsen
Row 4, Column 4
Never
Row 5, Column 0
Tried
Row 5, Column 1
Used often
Row 5, Column 2
Improves
Row 5, Column 3
Worsen
Row 5, Column 4
Never
Row 6, Column 0
Tried
Row 6, Column 1
Used often
Row 6, Column 2
Improves
Row 6, Column 3
Worsen
Row 6, Column 4
Never
Row 7, Column 0
Tried
Row 7, Column 1
Used often
Row 7, Column 2
Improves
Row 7, Column 3
Worsen
Row 7, Column 4
Never
Row 8, Column 0
Tried
Row 8, Column 1
Used often
Row 8, Column 2
Improves
Row 8, Column 3
Worsen
Row 8, Column 4
Never
Row 9, Column 0
Tried
Row 9, Column 1
Used often
Row 9, Column 2
Improves
Row 9, Column 3
Worsen
Row 9, Column 4
Never
Row 10, Column 0
Tried
Row 10, Column 1
Used often
Row 10, Column 2
Improves
Row 10, Column 3
Worsen
Row 10, Column 4
Never
Row 11, Column 0
Tried
Row 11, Column 1
Used often
Row 11, Column 2
Improves
Row 11, Column 3
Worsen
Row 11, Column 4
Never
Row 12, Column 0
Tried
Row 12, Column 1
Used often
Row 12, Column 2
Improves
Row 12, Column 3
Worsen
Row 12, Column 4
Never
Row 13, Column 0
Tried
Row 13, Column 1
Used often
Row 13, Column 2
Improves
Row 13, Column 3
Worsen
Row 13, Column 4
Never
Row 14, Column 0
Tried
Row 14, Column 1
Used often
Row 14, Column 2
Improves
Row 14, Column 3
Worsen
Row 14, Column 4
1 of 15
55
How does your dog respond to handling at home?Leave blank if you have not tried
Enjoys
Accepts willingly
Accepts reluctantly
Resists
Threats/Aggression
Nail trimming
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Ear clean
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Eye clean
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Brushing
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Bathing
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Brush teeth
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Pat head
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Rub belly
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Hug/Kiss
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Lifting
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Grab collar
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Give medication
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Removing food
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Removing toys
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Nail trimming
Ear clean
Eye clean
Brushing
Bathing
Brush teeth
Pat head
Rub belly
Hug/Kiss
Lifting
Grab collar
Give medication
Removing food
Removing toys
Enjoys
Row 0, Column 0
Accepts willingly
Row 0, Column 1
Accepts reluctantly
Row 0, Column 2
Resists
Row 0, Column 3
Threats/Aggression
Row 0, Column 4
Enjoys
Row 1, Column 0
Accepts willingly
Row 1, Column 1
Accepts reluctantly
Row 1, Column 2
Resists
Row 1, Column 3
Threats/Aggression
Row 1, Column 4
Enjoys
Row 2, Column 0
Accepts willingly
Row 2, Column 1
Accepts reluctantly
Row 2, Column 2
Resists
Row 2, Column 3
Threats/Aggression
Row 2, Column 4
Enjoys
Row 3, Column 0
Accepts willingly
Row 3, Column 1
Accepts reluctantly
Row 3, Column 2
Resists
Row 3, Column 3
Threats/Aggression
Row 3, Column 4
Enjoys
Row 4, Column 0
Accepts willingly
Row 4, Column 1
Accepts reluctantly
Row 4, Column 2
Resists
Row 4, Column 3
Threats/Aggression
Row 4, Column 4
Enjoys
Row 5, Column 0
Accepts willingly
Row 5, Column 1
Accepts reluctantly
Row 5, Column 2
Resists
Row 5, Column 3
Threats/Aggression
Row 5, Column 4
Enjoys
Row 6, Column 0
Accepts willingly
Row 6, Column 1
Accepts reluctantly
Row 6, Column 2
Resists
Row 6, Column 3
Threats/Aggression
Row 6, Column 4
Enjoys
Row 7, Column 0
Accepts willingly
Row 7, Column 1
Accepts reluctantly
Row 7, Column 2
Resists
Row 7, Column 3
Threats/Aggression
Row 7, Column 4
Enjoys
Row 8, Column 0
Accepts willingly
Row 8, Column 1
Accepts reluctantly
Row 8, Column 2
Resists
Row 8, Column 3
Threats/Aggression
Row 8, Column 4
Enjoys
Row 9, Column 0
Accepts willingly
Row 9, Column 1
Accepts reluctantly
Row 9, Column 2
Resists
Row 9, Column 3
Threats/Aggression
Row 9, Column 4
Enjoys
Row 10, Column 0
Accepts willingly
Row 10, Column 1
Accepts reluctantly
Row 10, Column 2
Resists
Row 10, Column 3
Threats/Aggression
Row 10, Column 4
Enjoys
Row 11, Column 0
Accepts willingly
Row 11, Column 1
Accepts reluctantly
Row 11, Column 2
Resists
Row 11, Column 3
Threats/Aggression
Row 11, Column 4
Enjoys
Row 12, Column 0
Accepts willingly
Row 12, Column 1
Accepts reluctantly
Row 12, Column 2
Resists
Row 12, Column 3
Threats/Aggression
Row 12, Column 4
Enjoys
Row 13, Column 0
Accepts willingly
Row 13, Column 1
Accepts reluctantly
Row 13, Column 2
Resists
Row 13, Column 3
Threats/Aggression
Row 13, Column 4
1 of 14
56
List all the problems that need to be addressedPlease list the more important/severe problems first
57
How often do the problems occur?Please describe individual problems.
Huge
Large
Normal
Small
Ok
Ok
58
Has there been a recent change in frequency or severity?
YESNO
59
Describe any changes in the home or your dog's health when the problem first started:
Huge
Large
Normal
Small
Ok
Ok
60
What do you think caused the problem?
Huge
Large
Normal
Small
Ok
Ok
61
List each behavioral treatment you have tried, and the dog's response
62
Indicate how your dog reacts to each of the following:
Calm
Friendly
Excited
Ambivalent
Confused
Fearful
Aggressive
Familiar dogs
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Unfamiliar dogs
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Cats
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Children
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Familiar people
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Unfamiliar people (outdoor)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Unfamiliar people (at home)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Visitors at door
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Row 7, Column 6
Cars
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Row 8, Column 6
Bikes/ Skateboards
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
Row 9, Column 6
Familiar dogs
Unfamiliar dogs
Cats
Children
Familiar people
Unfamiliar people (outdoor)
Unfamiliar people (at home)
Visitors at door
Cars
Bikes/ Skateboards
Calm
Row 0, Column 0
Friendly
Row 0, Column 1
Excited
Row 0, Column 2
Ambivalent
Row 0, Column 3
Confused
Row 0, Column 4
Fearful
Row 0, Column 5
Aggressive
Row 0, Column 6
Calm
Row 1, Column 0
Friendly
Row 1, Column 1
Excited
Row 1, Column 2
Ambivalent
Row 1, Column 3
Confused
Row 1, Column 4
Fearful
Row 1, Column 5
Aggressive
Row 1, Column 6
Calm
Row 2, Column 0
Friendly
Row 2, Column 1
Excited
Row 2, Column 2
Ambivalent
Row 2, Column 3
Confused
Row 2, Column 4
Fearful
Row 2, Column 5
Aggressive
Row 2, Column 6
Calm
Row 3, Column 0
Friendly
Row 3, Column 1
Excited
Row 3, Column 2
Ambivalent
Row 3, Column 3
Confused
Row 3, Column 4
Fearful
Row 3, Column 5
Aggressive
Row 3, Column 6
Calm
Row 4, Column 0
Friendly
Row 4, Column 1
Excited
Row 4, Column 2
Ambivalent
Row 4, Column 3
Confused
Row 4, Column 4
Fearful
Row 4, Column 5
Aggressive
Row 4, Column 6
Calm
Row 5, Column 0
Friendly
Row 5, Column 1
Excited
Row 5, Column 2
Ambivalent
Row 5, Column 3
Confused
Row 5, Column 4
Fearful
Row 5, Column 5
Aggressive
Row 5, Column 6
Calm
Row 6, Column 0
Friendly
Row 6, Column 1
Excited
Row 6, Column 2
Ambivalent
Row 6, Column 3
Confused
Row 6, Column 4
Fearful
Row 6, Column 5
Aggressive
Row 6, Column 6
Calm
Row 7, Column 0
Friendly
Row 7, Column 1
Excited
Row 7, Column 2
Ambivalent
Row 7, Column 3
Confused
Row 7, Column 4
Fearful
Row 7, Column 5
Aggressive
Row 7, Column 6
Calm
Row 8, Column 0
Friendly
Row 8, Column 1
Excited
Row 8, Column 2
Ambivalent
Row 8, Column 3
Confused
Row 8, Column 4
Fearful
Row 8, Column 5
Aggressive
Row 8, Column 6
Calm
Row 9, Column 0
Friendly
Row 9, Column 1
Excited
Row 9, Column 2
Ambivalent
Row 9, Column 3
Confused
Row 9, Column 4
Fearful
Row 9, Column 5
Aggressive
Row 9, Column 6
1 of 10
63
Does you dog react to noises or storm? If so, please describe the reactions.
Huge
Large
Normal
Small
Ok
Ok
64
Does you dog react to car rides? If so, please describe the reactions.
Huge
Large
Normal
Small
Ok
Ok
65
Does you dog fear of particular locations or situations? If so, please explain and describe the reactions.
Huge
Large
Normal
Small
Ok
Ok
66
After being exposed to a fearful event, how long does it take for your dog to return to normal?You can list out all the triggers
Huge
Large
Normal
Small
Ok
Ok
67
Does your dog have a housesoiling problem?Please describe the age began, frequency, location etc.
Yes
No
Please describe
Urine
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Feaces
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Urine
Feaces
Yes
Row 0, Column 0
No
Row 0, Column 1
Please describe
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Please describe
Row 1, Column 2
1 of 2
68
Does your dog have separation related problem for example anxiety, destruction etc.? Please describe.
Huge
Large
Normal
Small
Ok
Ok
69
During the average week, what is the longest time you would need to leave your dog alone?
70
How does your dog react when you prepare to leave?
71
Has your pet ever displayed any of the following?
Yes
No
Who was the target?
Please describe the last incident
Growling
Row 0, Column 0
Row 0, Column 1
Familiar people
Unfamiliar people
Dog
Other
Row 0, Column 2
Row 0, Column 3
Lifting lips
Row 1, Column 0
Row 1, Column 1
Familiar people
Unfamiliar people
Dog
Other
Row 1, Column 2
Row 1, Column 3
Bite attempts
Row 2, Column 0
Row 2, Column 1
Familiar people
Unfamiliar people
Dog
Other
Row 2, Column 2
Row 2, Column 3
Bite - released
Row 3, Column 0
Row 3, Column 1
Familiar people
Unfamiliar people
Dog
Other
Row 3, Column 2
Row 3, Column 3
Bite - no release or multiple bites
Row 4, Column 0
Row 4, Column 1
Familiar people
Unfamiliar people
Dog
Other
Row 4, Column 2
Row 4, Column 3
Growling
Lifting lips
Bite attempts
Bite - released
Bite - no release or multiple bites
Yes
Row 0, Column 0
No
Row 0, Column 1
Who was the target?
Familiar people
Unfamiliar people
Dog
Other
Row 0, Column 2
Please describe the last incident
Row 0, Column 3
Yes
Row 1, Column 0
No
Row 1, Column 1
Who was the target?
Familiar people
Unfamiliar people
Dog
Other
Row 1, Column 2
Please describe the last incident
Row 1, Column 3
Yes
Row 2, Column 0
No
Row 2, Column 1
Who was the target?
Familiar people
Unfamiliar people
Dog
Other
Row 2, Column 2
Please describe the last incident
Row 2, Column 3
Yes
Row 3, Column 0
No
Row 3, Column 1
Who was the target?
Familiar people
Unfamiliar people
Dog
Other
Row 3, Column 2
Please describe the last incident
Row 3, Column 3
Yes
Row 4, Column 0
No
Row 4, Column 1
Who was the target?
Familiar people
Unfamiliar people
Dog
Other
Row 4, Column 2
Please describe the last incident
Row 4, Column 3
1 of 5
72
If there was display of aggression, what is the potential for injury?
None
Minimum (superficial scratches, no medical attention needed)
Moderate (deep or infected wounds, require medical attention)
Severe (target the face/neck, life threatening)
Other
73
After your dog has bitten how do you handle the situation and what is your dog's reaction?
Huge
Large
Normal
Small
Ok
Ok
74
Please check if your pet exhibits any of the following behavior. If undesirable, please comment:
None
Occur, no concerns
Occur, want to improve
Describe
Vocalise bark/ whine/ howl
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Jumps up
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Pulls on leash
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Won't come when called
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Nips/ Grabs with mouth
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Pushy/ demanding
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Clingy
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Stool eating
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Eats non-food items
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Food stealing
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Destructive chewing
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Vocalise bark/ whine/ howl
Jumps up
Pulls on leash
Won't come when called
Nips/ Grabs with mouth
Pushy/ demanding
Clingy
Stool eating
Eats non-food items
Food stealing
Destructive chewing
None
Row 0, Column 0
Occur, no concerns
Row 0, Column 1
Occur, want to improve
Row 0, Column 2
Describe
Row 0, Column 3
None
Row 1, Column 0
Occur, no concerns
Row 1, Column 1
Occur, want to improve
Row 1, Column 2
Describe
Row 1, Column 3
None
Row 2, Column 0
Occur, no concerns
Row 2, Column 1
Occur, want to improve
Row 2, Column 2
Describe
Row 2, Column 3
None
Row 3, Column 0
Occur, no concerns
Row 3, Column 1
Occur, want to improve
Row 3, Column 2
Describe
Row 3, Column 3
None
Row 4, Column 0
Occur, no concerns
Row 4, Column 1
Occur, want to improve
Row 4, Column 2
Describe
Row 4, Column 3
None
Row 5, Column 0
Occur, no concerns
Row 5, Column 1
Occur, want to improve
Row 5, Column 2
Describe
Row 5, Column 3
None
Row 6, Column 0
Occur, no concerns
Row 6, Column 1
Occur, want to improve
Row 6, Column 2
Describe
Row 6, Column 3
None
Row 7, Column 0
Occur, no concerns
Row 7, Column 1
Occur, want to improve
Row 7, Column 2
Describe
Row 7, Column 3
None
Row 8, Column 0
Occur, no concerns
Row 8, Column 1
Occur, want to improve
Row 8, Column 2
Describe
Row 8, Column 3
None
Row 9, Column 0
Occur, no concerns
Row 9, Column 1
Occur, want to improve
Row 9, Column 2
Describe
Row 9, Column 3
None
Row 10, Column 0
Occur, no concerns
Row 10, Column 1
Occur, want to improve
Row 10, Column 2
Describe
Row 10, Column 3
1 of 11
75
Please check if your pet exhibits any of the following behavior. If undesirable, please comment:
None
Occur, no concerns
Occur, want to improve
Describe
Digging
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Night waking
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Spinning/ tail chasing
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Licks objects
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Excessive grooming
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Staring
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Stargazing
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Fly chasing
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Light chasing
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Mounting
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Masturbation
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Roaming/ running away
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Digging
Night waking
Spinning/ tail chasing
Licks objects
Excessive grooming
Staring
Stargazing
Fly chasing
Light chasing
Mounting
Masturbation
Roaming/ running away
None
Row 0, Column 0
Occur, no concerns
Row 0, Column 1
Occur, want to improve
Row 0, Column 2
Describe
Row 0, Column 3
None
Row 1, Column 0
Occur, no concerns
Row 1, Column 1
Occur, want to improve
Row 1, Column 2
Describe
Row 1, Column 3
None
Row 2, Column 0
Occur, no concerns
Row 2, Column 1
Occur, want to improve
Row 2, Column 2
Describe
Row 2, Column 3
None
Row 3, Column 0
Occur, no concerns
Row 3, Column 1
Occur, want to improve
Row 3, Column 2
Describe
Row 3, Column 3
None
Row 4, Column 0
Occur, no concerns
Row 4, Column 1
Occur, want to improve
Row 4, Column 2
Describe
Row 4, Column 3
None
Row 5, Column 0
Occur, no concerns
Row 5, Column 1
Occur, want to improve
Row 5, Column 2
Describe
Row 5, Column 3
None
Row 6, Column 0
Occur, no concerns
Row 6, Column 1
Occur, want to improve
Row 6, Column 2
Describe
Row 6, Column 3
None
Row 7, Column 0
Occur, no concerns
Row 7, Column 1
Occur, want to improve
Row 7, Column 2
Describe
Row 7, Column 3
None
Row 8, Column 0
Occur, no concerns
Row 8, Column 1
Occur, want to improve
Row 8, Column 2
Describe
Row 8, Column 3
None
Row 9, Column 0
Occur, no concerns
Row 9, Column 1
Occur, want to improve
Row 9, Column 2
Describe
Row 9, Column 3
None
Row 10, Column 0
Occur, no concerns
Row 10, Column 1
Occur, want to improve
Row 10, Column 2
Describe
Row 10, Column 3
None
Row 11, Column 0
Occur, no concerns
Row 11, Column 1
Occur, want to improve
Row 11, Column 2
Describe
Row 11, Column 3
1 of 12
76
What are your goals for this consultation?
Huge
Large
Normal
Small
Ok
Ok
77
Have you considered removing your pet from the home (rehoming or euthanasia) if the problem cannot be improved?
YESNO
78
Please upload any pictures and/or videos that would help me to understand your dog's problem better. You can also show me the videos during the consultation.
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