Your Name
First Name
Last Name
Email
example@example.com
Pet's Name
Breed
Date of Birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Spayed/Neutered
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
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What is the main behavior problem or complaint?
Additional Problems?
How frequently does the problem (or problems) occur (how many times daily, weekly or monthly)?
When did you first notice the main problem (age of dog)?
When did it first become a serious concern?
In what general circumstances does the dog misbehave?
Has the problem changed in frequency? (please describe)
Has the problem changed in intensity? (please describe)
Has the problem changed otherwise?
Describe several examples in detail:
Most recent incident with date:
Second to last incident with date:
Third to last incident with date:
Other significant incidents:
What have you done so far to try to correct the problem?
How do you discipline your dog for this and for other misbehavior?
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Please list the people, including yourself, living in your household. Please include ages of children
Please list all animals in the household including patient: (Include Name, species, breed, sex, age obtained, age now)
In what sequence were the above animals obtained? (Please number animals in the table above)
What is your dog's relationship to the other animals? (eg. friendly, hostile, fearful?) Please describe:
City/Town
City/Town
Suburbs
Rural
Other
What type of house do you live in? Please describe
Have you moved since acquiring your dog?
Yes
No
How many times?
Has your household (people or animals) changed since acquiring your dog?
Yes
No
Please describe:
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Why did you decide to get a dog?
Why did you choose this breed?
Where did you get this dog?
SPCA
Breeder-newspaper ad/flyer
Breeder-referral
Pet store
Friend
Stray
Other
Where did you get this dog? - Details
Have you owned dogs previously?
Yes
No
Why did you choose this dog over the others?
If known: how many littermates? (Males, Females)
How many animals to choose from?
Was a temperament test performed?
Yes
No
Unsure
Result:
Describe your dog's behavior as a puppy:
Do you have any news about littermate behavior? (Please describe)
Did you meet the parents?
Yes
No
If yes, please descibe their behavior:
Has this dog had other owners?
Yes
No
How many?
Why was the dog given up?
At what age was your pet neutered/spayed?
Why was this done?
Were there any behavior changes after neutering or spaying?
If your pet was "intact" has he/she ever been bred?
Yes
No
Unsure
Are you planning to breed?
Yes
No
Unsure
If you have an intact female, when was her last heat? Was it normal?
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What do you feed your dog? (Please be specific, eg. brand name)
Has your dog's appetite changed?
How much do you feed? (Please be specific)
Who feeds the dog?
Location of feeding:
What's your dog's favorite treat?
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Please describe a typical 24-hour day in your dog's life:
How does the dog behave with familiar visitors?
How does the dog behave with unfamiliar visitors (children or adults)
How do you exercise your dog?
Is the dog free in a fenced yard?
Is your dog free to go in and out of yard unsupervised?
Is the dog tied outside?
Yes
No
Does the dog run free? Under what circumstances?
How do you play with your dog?
What toys does the dog have?
is your dog housetrained?
Yes
No
How was the dog housetrained?
Does your dog ever eliminate in the house?
No
Yes
Urinate
Defecate
Does your dog ever eliminate in the house? Where? Frequency? Any common triggers for this behavior?
Where does your dog sleep at night?
What is your dog's sleep pattern? Has there been any changes?
What arrangements do you have for your dog when no one is home?
How long are they typically alone?
Where is your dog when you have guests?
How does your dog behave while you are leaving the house?
How do you interact with your dog at this time?
How does your dog behave when you return?
How do you respond?
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What basic obedience training has your dog had?
None
Trained at home
Started obedience classes but didn't finish
Graduated obedience class once
Graduated obedience class two or more levels
Private trainer
Other
How did your dog respond to the training?
What type of training tools have you used (choke chains, prong collar, head halter, shock collars, treats)? Do you currently use any of these?
How old was the dog when obedience training started?
Who in the family is the primary trainer?
Does your dog have any awards or titles? (Please describe)
Has your dog had any hunting, herding, protection, attack, or Shutzhund training?
Hunting
Herding
Protection
Attack
Schutzhund
Other
Out of 10 times, how many times will your dog obey you?
Out of 10 times, how many times will your dog obey family members?
Does your dog know any tricks? (Please describe)
Have you exhibited your dog in breed shows?
Yes
No
No, but I plan to
Does your dog jump on you or others without permission?
Does your dog paw at you or others?
Does your dog lick you or others?
Does your dog mount you or others? If yes, Whom?
Does your dog mount other animals or objects?
Does your dog bark at you? If yes, How do you respond?
Does your dog bark at others? Growl at others?
Does your dog bark at other times?
What is your dogs activity level in general?
Low
Average
High
Excessive
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Is your dog on any medication now, for this or other problems?
Has your dog been on medication in the past?
Date of the most recent rabies vaccination:
Did you notice a change in behavior after rabies vaccine was given?
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Pet dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Hug dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Kiss dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Lift dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Call off furniture
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Push/Pull off furniture
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Approach on furniture
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Disturb while resting/sleeping
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Approach while eating
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Touch while eating
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Take dog food away
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Take human food away
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Take water dish away
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Take rawhide
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Take biscuit/cookie
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Take real bone
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Take toy/object
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Approach when dog has any toy/object/bone
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Verbally punish
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Physically punish
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Visual threat
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Speak to dog (normal tone)
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Stare at dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Bend over dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Push on shoulders or back
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Approach dog near significant other
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Enter room
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Leave room
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Reach toward dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Leash restraint
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Collar restraint
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Scruff restraint
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Put leash on/take off
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Put collar on/take off
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Bathe dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Towel dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Groom/brush dog
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Dog at groomers
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Trim nails
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Leash/collar correction
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Response to "sit"
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Response to "down"
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Dog at veterinary clinic
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Unfamiliar adult enters house or yard
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Unfamiliar child enters house or yard
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Familiar adult enters house or yard
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Response to toddlers/babies
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Dog in response to tollbooths/gas stations
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Unfamiliar adult approaches, dog on leash
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Unfamiliar child approaches, dog on leash
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Dog in house, sees people outside
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Response to other dogs while on leash
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Response to other dogs, while not on leash
GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
RF - Responds favorably
NA - Not applicable
Where are you on a scale of 1 to 5 as follows
Please Select
1. I am here only out of curiosity - problem is not serious
2. I would like to change the problem, but it is not serious
3. The problem is serious and I would like to change it, but if it remains unchanged that's all right.
4. The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog.
5. The problem is very serious and I would like to change it, if it remains unchanged I will have my dog euthanized or give him/her up.
Where are you on a scale of 1 to 5 as follows
1. I am only here out of curiosity- problem is not serious
2. I would like to change the problem, but it is not serious
3. The problem is serious and I would like to change it, but if it remains unchanged that's all right
4. The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog
5. The problem is very serious and I would like to change it, if it remains unchanged I will have my dog euthanized or give him/her up
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For Aggression (Towards people) (Skip this section if aggression is not the problem Please answer yes or no to these characteristics of your dog's behaviour:
Attacks are sudden and surprising
Yes
No
Episodes appear unprovoked
Yes
No
The dog is abruptly docile after an episode
Yes
No
The dog appears "sorry" afterwards
Yes
No
The dog appears disoriented afterwards
Yes
No
Episodes are associated with a "glazed" or "absent" expression
Yes
No
I can usually tell what will set off my dog
Yes
No
The aggressive behaviour is new and uncharacteristic
Yes
No
Has your dog bitten and broken skin?
Yes
No
Number of bites that broke skin
Total number of bites (that did or did not break skin)
Total number of episodes of aggression (growling, snapping, biting)
Describe typical episode (eg. does dog growl, lunge or bite, and in what circumstance)
If the dog is in the above situation 10 times, in how many of those times is aggresion seen (eg. all=100%, just one=10%, etc.)
What parts of the body has the dog bitten and how severe were the injuries?
Who is/are the target(s) of aggression?
Did your dog bite as a puppy?
Yes
No
If yes, please describe, including age
How old was your dog the first time he/she growled at a person?
What was the circumstance?
How old was your dog the first time he/she snapped or bit at a person?
What was the circumstance?
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How much time are you willing to spend working with your dog daily/weekly?
*
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