Behavior Assessment Form

Pet's Name* This field is required.

Client First and Last Name* This field is required.

Client Email* This field is required.

example@example.com

How did you acquire your pet (breeder, shelter, rescue, etc) and when?* This field is required.

Age of your pet at acquisition* This field is required.

How much interaction did your pet have with people and the other animals in their first year of life?* This field is required.

Briefly describe your pet's overall personality.* This field is required.

Describe the behavioral problem you are currently having with your pet.* This field is required.

When did this behavior start?* This field is required.

Have you tried any medications or behavior modifications/training for this problem? If so, please explain what and if it helped or not.* This field is required.

Do you suspect any cause?* This field is required.

Describe the two most recent incidents.* This field is required.

Describe your pet's body posture during these episodes (example: ears back, wide eyes, etc). Was there any warning prior to the reaction?* This field is required.

What was your (or your family's) reaction to these episodes?* This field is required.

What was your dog's response to your reaction?* This field is required.

If aggression is present, what was the result to the victim?* This field is required.(Check all that apply)

No Injuries

Bruise

Scratch

Puncture

Deep Puncture (>0.5" in depth)

Tearing

Required Medical Treatment

Other

If "Other" was selected above, please explain:

How often do these incidents occur? Example: daily, weekly, monthly etc* This field is required.

Are there any other details surrounding these incidents you feel are relevant?* This field is required.

Please input any products, supplements, or medications that you use with your pet.* This field is required.

Does your pet have any chronic medical conditions? Please describe and provide treatment details.

Please list the human and pet occupants in your home:* This field is required.

In what sort of home do you and your pet reside?* This field is required.

Single Family Home

Townhouse

Condo/Apartment

Other

How would you describe the energy of your home?* This field is required.

Quiet, slow, routine

Moderately active, some sporadic changes

High energy, lots of people coming and going. Noisy.

Is your pet protective of their food?* This field is required.

Yes

With family members

With strangers

With other pets

With visiting pets

Where does your pet sleep?* This field is required.

Does your pet wake you up at night?* This field is required.

Where can your pet normally be found during the day?* This field is required.

How long does your pet like to be outside?* This field is required.

Do you have a backyard? If yes, please select all that apply:* This field is required.

Yes

Unfenced

Electric Fence

See Through Fencing (panels, chicken wire, etc.)

Privacy Fencing

Small (100 sq ft or less)

Medium (0.5-1 acre)

Large (>1 acre)

Is your pet affectionate or cuddly?* This field is required.

Yes

Sometimes

What type of exercise does your pet get on a daily basis?* This field is required.

None

1-3 Sessions per Day

4-6 Sessions per Day

>6 Sessions per Day

Short Walk

Long Walk

Jogging/Running

Treadmill

Fetch

Wrestling/Tug-Style Play

Agility

Other

Describe "other" is applicable.

Is your pet playful?* This field is required.

Yes

Sometimes

Explain Below:

What kind of play do they enjoy the most?

What type of objects do they chew? Any destructive behaviors?* This field is required.

Where does your pet stay when no one is home?* This field is required.

What does your pet do as you prepare to leave?* This field is required.

Do you record or monitor your pet when they are home alone?* This field is required.

Yes

Sometimes

Approximately how long is your pet left home alone each day?* This field is required.

Does your pet exhibit any of the following behaviors either as you prepare to leave or once you are gone?* This field is required.

Pacing and/or panting for extended periods of time

Vocalization such as whining, crying, barking, etc.

Destruction of windows and/or doorways

Urination and/or defecation

Excessive drooling

Vomiting

None of the above

How would you describe your pet's ability to learn?* This field is required.

Poor

Average

Good

Great

Is there any specific time devoted to training per day?* This field is required.

Yes

Have you ever attended any professional, group classes?* This field is required.

YESNO

If yes, provide the name of the facility, the instructor, and the topic of the class:

Have you ever had a private trainer work with you and/or your pet?* This field is required.

YESNO

If yes, provide the training group, the trainer's name, and the skills covered:

Has your pet ever gone to a board and train facility?* This field is required.

YESNO

If yes, provide the clinic/group's name, individual's name, and topics covered:

Which cues or commands does your pet respond to reliably?

Come

Sit

Down

Stand

Leave It

Drop It

Touch

Wait/Stay

Place/Settle

Does your pet pull on leash?* This field is required.

Yes - Always

Yes - Sometimes

Yes - Rarely

No - Use training collar(s)

No - Never pulls

No - We don't go for walks

How do you correct your pet when they misbehave?* This field is required.

What training aides are you CURRENTLY using?* This field is required.

Treats

Flat collar

Martingale collar

Body harness

Head collar/Halter

Slip collar/choke chain

Metal prong/pinch collar

Plastic prong/pinch collar

Vibration collar

Vibration/electric/stim collar - underground fence only

Vibration/electric/stim collar - remote operated

What training aides did you use PREVIOUSLY?* This field is required.

Treats

Flat collar

Martingale collar

Body harness

Head collar/Halter

Slip collar/choke chain

Metal prong/pinch collar

Plastic prong/pinch collar

Vibration collar

Vibration/electric/stim collar - underground fence only

Vibration/electric/stim collar - remote operated

Any other comments pertaining to training?

Does your pet demonstrate any aggression in the following circumstances? (aggression is defined as any "distance increasing" behavior and can include staring, snarling, growling, snapping, muzzle punching, biting, etc.)

If any of the boxes above are checked, please explain:

How does your pet respond when someone rings the doorbell or knocks on the door?* This field is required.

Is your pet quick to approach visitors in the home?* This field is required.

Yes

Sometimes

Describe your pet response to the following situations:* This field is required.

Does your pet show any inappropriate mounting or sexual behavior?* This field is required.

YESNO

Is your pet protective of any parts of his or her body?* This field is required.

YESNO

If "yes," which parts and what does he or she do?

Are there any other behaviors you find objectionable?

Using the below scale, please rank how difficult it is living with this pet. 1 means we are getting rid of the dog right now and 10 means your dog is perfect and easy to live with.* This field is required.

What is the family's thoughts on the current problem(s)?* This field is required.

What are your expectations for change?* This field is required.

What are your goals for treatment?* This field is required.

Under what circumstances would you rehome this pet?* This field is required.

Under what circumstances would you relinquish or put this dog up for adoption?* This field is required.

Under what circumstances would you euthanize this pet?* This field is required.