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.

MaleFemale

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.

BreederAnimal ShleterFriendOther (Please specify below)

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?

Briefly describe your dog’s daily exercise routine:

AMPM

Describe your dog's feeding habits:

Ball TimeChase gamesTugOther

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:

CompanionFor ChildProtectionWork (Specify Below)

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?

YesNo

Describe your dog's reaction to being left alone:

YesNo

2 Hours5 Hours10 Hours15 Hours

YesNo

If yes, please specify nicknames:

YesGoodOther

NoAhHeyOther

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?

YesNo

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?

NeverOccasionallyOften

Please give details of any compulsive habits displayed

NeverOccasionallyOften

Please explain:

NeverOccasionallyOften

Describe any problem not listed:

YesNo

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

YesNo

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

YesNo

If yes, please explain:

NeverOccasionallyOfter

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?

YesNo

If yes, what animal has your dog killed?

YesNo

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

YesNo

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?

YesNo

1-2 times3-5 times6-10 times

Level 1 Bite – Harassment but no skin contact. This is the so-called snap. An intended “air bite” from a dog who did not intend to connect. He didn’t just “miss.” It is a lovely warning signal.Level 2 Bite – Tooth contact on skin but no puncture. Again, this is a bite from a dog who didn’t intend to break skin, and a warning that this dog is serious.Level 3 Bite – Skin punctures, one to four holes from a single bite (all punctures shallower than the length of the canine tooth).Level 4 Bite – One to four holes, deep black bruising with punctures deeper than the length of the canine (which means the dog bit and clamped down) or slashes in both directions from the puncture (the dog bit and shook his head).Level 5 Bite – Multiple-bite attack with deep punctures, or multiple attack incident.Level 6 Bite – Killed victim and/or consumed flesh.

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?)

YesNo

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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