Congratulations on taking the first step toward lasting behavior change. Please fill out the following form as accurately as possible. If you are unsure about a question or feel it doesn't apply to your situation, leave it blank. Looking forward to working with you and your dog!
Best,
Ruth Crisler, CBCC-KA
Contact Information
Name(s)
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Email(s)
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Phone(s)
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Dog Information
Dog's Name
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Dog's Age (date of birth if known)
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Dog's age when adopted or purchased
Sex of Dog
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Male
Female
Spay/Neuter Status
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Intact
Spayed/Neutered
Breed or Type
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Vaccinations
Are your dog's vaccinations current?
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Veterinarian or Veterinary Hospital with your dog's records on file
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Reason for Behavior Evaluation
Summarize your primary training or behavior goal(s).
Please check off any additional issues.
Not housebroken
Urinates when excited or afraid
Jumps up
Overactive/doesn't settle easily
Nervous or easily stressed
Fearful or shy
Nuisance barking
Demanding barking
Chews destructively
Bolts through open doors
Pulls on leash
Doesn't come when called
Unresponsive to name or commands
Inattentive/short attention span
Play biting/mouthing
Steals food or objects
Guards food, toys or objects
Guards people
Guards space or territory
Aggressive toward people
Aggressive toward dogs
Growls at family members
Has injured one more person
Has injured one or more dog
Separation Anxiety
Other
If has bitten or caused injury to a person, please explain.
If has bitten or caused injury to another dog, please explain.
Describe the most serious incident that has so far occurred (please note when this happened).
How often is the main problem occurring?
Once a month or less
No more than once a week
Several times a week
Every day
Multiple times per day
This problem is increasing in
Frequency
Intensity
Duration
None of the above
What have you done to address or correct the above issues?
Were these methods effective? (Please explain.)
Household Information
How many adults reside in your household? (Please list.)
How many children? (Please list names and ages.)
What other pets do you own?
Do you have a yard?
Where does your dog sleep?
Do you crate your dog? If so, when and how does he tolerate it?
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General History
Where did you purchase or adopt?
Is your dog social with new people?
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Is your dog social with other dogs?
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How much social interaction with other dogs has your dog had, either on-leash or off?
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If you have worked with a trainer or behaviorist previously, describe what that entailed.
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Check off any commands or skills your dog knows or has.
Sit
Down
Stay
Come
Heel
Off
Leave It
Loose-leash Manners
Touch
Watch Me
Out
Drop
Free
Okay
Hand Signals
Other commands or skills
Health History
What do you feed your dog, how often, and how much?
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Please list any current or recent medications. If current, please give dosage and schedule.
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Please confirm the following:
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I verify all the above answers are accurate to the best of my knowledge.
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