Bite Threat/Bite Event Questionnaire

Bite Threat/Bite Event Questionnaire

This form must be completed and submitted prior to consult/first appointment.
I greatly appreciate you taking the time to complete this questionnaire. The information will be used solely to review your dog’s bite threat(s)/bite event(s) and to help me prepare a plan for training or behavior modification.

Please review this entire questionnaire first, then go back and answer the questions as thoroughly as possible. Please ask anyone who witnessed the bite event(s) for their input as well.

The information contained herein will only be shared with another trainer, veterinarian, veterinary specialist or veterinary behaviorist with your permission.
Client Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone*
Email*
Pet Information
Dog's Name
Breed / Mix
Color / Markings
Age
Weight
Gender
Is Your Dog

SpayedNeutered
Dog's Name
Breed / Mix
Color / Markings
Age
Weight
Gender
Is Your Dog

SpayedNeutered
Dog's Name
Breed / Mix
Color / Markings
Age
Weight
Gender
Is Your Dog

SpayedNeutered
Bite Incident(s)

Please provide details for any/all bite events, including near bite events
Has Your Dog Threatened and / or Bitten ANY PERSON?

YesNoBoth
If your dog has threatened / bitten another PERSON(s), please provide as much detail about each incident that you can. Please indicate what led up to the incident, the incident itself and the behavior of your dog afterward.
Your dog (choose all that apply):

Was in your yardWas inside your homeWas in another locationWas on leash on a walkWas on leash and approached the personWas on leash and approached by the personWas off leash and approached the personWas off leash and approached by the personWas playing with the personWas attacked by the personAttacked the person without any apparent warning
The PERSON (choose all that apply):

Was a family memberWas a visitor to your homeWas a stranger in publicWas a veterinarianWas a vet techWas a groomerWas a pet sitter / dog walkerWas threatened by growlingWas threatened by barkingWas threatened by showing of teeth / snarlingWas threatened by being lunged atSuffered no apparent injurySuffered bruisingSuffered a single puncture woundSuffered broken skinSuffered multiple puncture woundsRequired medical attentionRequired hospitalization
What area of the person's body was injured? Provide details on any medical attention needed/provided:
Was the Bite Reported to Police / Health Authorities?

YesNoUnknown
Was Your Dog Quarantined at:

Your HomeVet OfficeOther FacilityNot Quarintined
Did any type of legal action, civil or criminal, arise from the bite incident?
Has Your Dog Threatened / Bitten Another ANIMAL?

YesNoBoth
If your dog has threatened / bitten another ANIMAL(s), please provide as much detail about each incident that you can. Please indicate what led up to the incident, the incident itself and the behavior of your dog afterward.
Your dog (choose all that apply):

Was off leash in your yardWas off leash in another locationWas on leash on a walkWas on leash and approached a leashed other animalWas on leash and approached an off leash other animalWas off leash and approached a leashed other animalWas off leash and approached an unleashed other animalWas playing with the other animalWas attacked by the other animalAttacked the other animal without any apparent warning
The ANIMAL (choose all that apply):

Was a family memberWas a visitor to your homeWas a stranger in publicWas at the veterinarianWas with a vet techWas at the groomerWas off leash and approached your dogWas on leash and approached your dogPlay escalated into an incidentWas threatened by growlingWas threatened by barkingWas threatened by showing of teeth / snarlingWas threatened by being lunged atSuffered no apparent injurySuffered bruisingSuffered a single puncture woundSuffered broken skinSuffered multiple puncture woundsRequired medical attentionRequired hospitalization
What area of the animal's body was injured? Provide details on any medical attention needed/provided:
Was the Bite Reported to Police / Health Authorities?

YesNoUnknown
Was Your Dog Quarantined at:

Your HomeVet OfficeOther FacilityNot Quarintined
Did any type of legal action, civil or criminal, arise from the bite incident?
If there has been more than 1 bite event, please complete a separate Bite Event Questionnaire for each event.
By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I further agree that my signature on this document is as valid as if I signed the document in writing.
Please visit my website to learn more about my training, education, methods, skills, credentials and history

www.theinnerdog.com
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