Canine Valley Dog Intake

Name

First NameLast Name

Phone Number

Area CodePhone Number

How did you hear about us?

Please include all family members, including pets & your occupations

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

CASE INFORMATION PLEASE ANSWER THE FOLLOWING QUESTIONS. ALL INFORMATION YOU PROVIDE IS CONFIDENTIAL. IT IS IMPORTANT TO ANSWER CAREFULLY AS THE INFORMATION WILL BE USED TO ASSESS YOUR DOG. PLEASE ADD ANY ADDITIONAL INFORMATION AS YOU SEE FIT.

Sex

Dog's Name

Breed/Mix of Dog

Date of Birth

Status

Age when Altered

Did you notice any short- or long-term changes in your dog’s behaviour after altering? Was your dog altered because of a behaviour problem? If yes, explain.

Are your dogs vaccinations up to date?

Does your dog have any medical conditions? If yes, please explain.

List all medications your dog is currently taking:

How old was your dog when you acquired it?

Has your dog had any pervious owners? If yes, please explain.

Where did you get your dog?

If you got your dog from a breeder or chose other, please specify their information:

Is your dog kept outdoors? If so, where?

How does your dog spend the majority of its time?

How often do you exercise your dog?

For how long?

Briefly describe your dog’s daily exercise routine:

When is your dog fed? (if both, select both)

What do you feed your dog?

Describe your dog's feeding habits:

What sort of play does your dog enjoy most?

Where does your dog sleep?

Please describe the general social layout of the family (adults, children, and animals) and the dog’s place in it:

Has your household changed since acquiring your dog? If yes, please describe.

Does your dog enjoy children? If no, please explain.

Describe how your dog reacts to guests and strangers:

Describe how you would like your dog to react to guests and strangers:

Describe your dog's interaction with other animals in the household:

Describe your dog's behaviour around other dogs: Briefly describe your experience and whether the dog(s) had any behaviour problems.

Describe how you would like your dog to react to other dogs:

Why did you decide to get a dog?

Why did you choose this specific breed/dog?

Is your dog going to perform any work? If so please describe the type of work your dog will be participating on.

Describe your dog's behaviour as a puppy. Anything unusual?

Does your dog spend time alone everyday?

Describe your dog's reaction to being left alone:

Do you use a crate for your dog?

How many hours a day is your dog kept in a crate? Less than…

Does your dog know his or her name?

Does your dog have any nick names that you use on a regular bases?

If yes, please specify nicknames:

What command do you use to indicate to your dog when he or she has done something correctly?

What command do you use to indicate to your dog that he or she has done something that you consider inappropriate?

Has your dog ever been to obedience school? If yes, how many weeks of training?

What training methods or philosophy did the trainer emphasize?

Describe your impressions and benefits from training:

Does your dog come when called?

Does your dog pull when being walked?

Describe your dog's general attitude and response to obedience training:

Describe any kind of behaviours would you like your dog to perform for you. These can be obedience commands or tricks

What do you consider to be your dog’s most undesirable behaviour?

When did you first notice this behaviour?

Rank the severity of your dogs problem:

How often does the problem occur?

Has there been a recent change in frequency or severity?

Have there been any changes in the household that could help explain the appearance of the problem?

Has your dog been in any pain or physical discomfort recently? If so please explain?

When was the last time your dog had a veterinarian examination?

What have you done so far to correct your dog’s behaviour problem?

Why do you think the dog is exhibiting the behaviour problem?

Does your dog bolt out of the house if the door is open?

House soiling (urination, defecation, marking, submissive urination):

Excessive barking or howling:

Coprophagia (stool eating, other animal’s feces):

Destructiveness (scratching, chewing, digging):

Jumping up (on guests or owners):

Mouthing on hands or clothing:

Chases (cars, people, other dogs, bikes):

Object and food stealing:

Does your dog attempt to run away when caught:

Dominance Testing (pushy behaviour):

Sexual behaviour (thrusting against humans, inanimate objects, roaming):

Compulsive habits (paw licking, flank sucking, cloth sucking, whirling, tail chasing, other):

Please give details of any compulsive habits displayed

Overly submissive behaviour (such as peeing when greeted):

Fearfulness (shy or phobic reactions):

Please explain:

Excessive excitability and impulse-control deficits:

Sleep Problems:

Describe any problem not listed:

Do you ever feel afraid of your dog?

If you do feel afraid please explain in what circumstances does this happen

Does your dog threaten or exhibit aggression toward family members?

Describe all episodes of aggression (including threats) towards family members:

Does your dog ever react aggressively to grooming and other handling efforts?

Is your dog aggressive towards non-family members?

If yes, please explain:

Eating:

Playing:

Chewing on a toy:

When approached while sleeping:

When people visit:

When reached for or touched:

When being groomed:

While being put into a crate:

How old was your dog when it exhibited the first signs of aggressiveness?

Is there anyone who the dog is never aggressive towards?

Does your dog suffer from any physical condition that might explain its aggressiveness?

Is your dog more aggressive towards:

Has your dog ever killed any animals?

If yes, what animal has your dog killed?

Do you know what fear looks like in dog language?

Please describe what you consider a fear response in your dog:

Does your dog show signs of fear prior to becoming aggressive?

If yes, please explain what you consider to be the fear response in your dog. What does your dog do or look like?

Will your dog lie down on command?

Has your dog ever bitten a person or a dog?

If so, how many times?

Describe the severity of past bites

Please explain all bite incidents with as much detail as possible. When did it happen?, Where did it happen?, Who was there?, What was happening?, How fast did it occur?, How did you stop it? What were the injuries if any?

Describe in detail the last bite incident (what, when, where, why?)

Have you had any dogs prior to this one?

What do you enjoy most about your dog?

What is your favourite activity to engage with your dog?

If you had the perfect dog as your companion what would his or her characteristics be?

General Infomation

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