Paws and Effect Dog
Dog info sheet
Human information
Appointment date
*
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Month
-
Day
Year
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Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Name
*
First Name
Last Name
Home Phone
*
Cell Phone
E-mail
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Names and ages of other humans in the household?
*
How did you hear about Paws and Effect?
Dog Information
Dog's name
*
Date of birth (best guess)
*
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Month
-
Day
Year
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Breed (best guess)
*
Gender
*
Male
Female
Spayed / neutered
*
Yes
No, not planning to
Not yet but planning to
If yes, at what age?
Name of veterinarian
*
When was the last time your dog saw the vet?
*
If less than 6 months ago what was the reason for your visit & the outcome?
Does your dog have any medical issues, allergies or physical limitations? If so, please list:
*
Where did you get your dog?
*
How long have you had your dog?
*
Has your dog had previous training?
*
Yes
No
Unknown
Seems to have had training
If yes, at what age?
Type of training
Group classes
Private lessons
I did my own training
Name of trainer(s)
Is this your first dog?
*
Yes
No
If this is not your first dog how long has it been since you've lived with a dog?
0 - 5 years
5 - 10 years
More than 10 years
I currently have another dog
Is your dog crate trained?
*
Yes
No
In process
Unknown
Where does your dog sleep?
*
Is your dog allowed on the furniture?
*
Yes, all furniture
Yes, one specific piece of furniture
Only when invited
Sometimes
Only when invited
Other
Do you have a dog door?
*
Yes
No
Percent of time dog spends indoors?
*
Where does your dog stay when no one is home?
*
Does your dog attend daycare or dog parks?
*
Yes
No
If yes to either please state which and how often
What brand / type of food does your dog eat?
*
How many times a day do you feed your dog?
*
One
Two
Three
The food is left out all day
Does your dog finish all the food at the time you present it?
*
Yes
Almost always
50 / 50
Rarely
Do you ever add things to the food to get your dog to eat? If so, please describe:
*
Does your dog play with toys?
*
Yes, often
Sometimes
No, never
What types of games do you play with your dog? (check all that apply)
*
Fetch
Wrestle / Rough housing
Chase (dog chases me)
Chase (I chase the dog)
Tug 'o War with you
Slappy head (hands moving around dog's face/head)
Other
What type of collar do you use for walking / training?
*
Flat / buckle
Head halter
Choke chain
Pinch / prong collar
No-pull harness
Body harness
Martingale
Other
What type of leash do you walk with?
*
Leather
Nylon
Retractable
Other
Describe in detail your dog's behavior when someone they've never met comes into your home.
*
What kind of training does your dog need?
*
Basic
Behavior
Other
If a "behavior issue" or "other" please describe
How long ago did you first notice these issues?
What have you done to change this behavior?
Did the problem become...
Better
Worse
Stayed the same
Has your dog ever bitten a person?
*
Yes
No
Unknown
Has your dog ever bitten another animal?
*
Yes
No
Unknown
If yes to either, was the skin broken?
*
Yes
No
Unknown
N/A
If skin was broken was medical care sought?
*
Yes
No
Unknown
N/A
If your dog has bitten either a person or animal, describe the incident in detail:
*
List 3 things you want your dog to learn:
*
Please list the things you like about your dog:
*
What are your dog's favorite things?
*
What are your dog's least favorite things?
*
How much time do you spend training your dog, and what do you do?
*
Is there anything else you want me to know about your dog or situation?
Terms of service
*
By submitting this form I confirm that I am at least 18 years of age and agree that all the information provided is true and correct to the best of my knowledge. I also acknowledge that the training rates have been provided to me and agree to payment in full at the end of the first session. I understand that if I need to cancel/reschedule my appointment(s), a minimum of 24 hours advanced notice must be provided to Jill Johnson / Paws and Effect Dog via email; if I do not notify Jill Johnson / Paws and Effect Dog within this time period I will be charged a cancellation fee of $50 and/or forfeit any pre-paid session(s). No refunds or exchanges.
Liability release
*
I forever waive and release Jill Johnson / Paws and Effect Dog her family, heirs, acquaintances and agents, or any person acting on her behalf or at her request from any and all liability and/or demands which I, for myself, my heirs, executors, personal and/or legal representatives or assigns may have or hereafter have, at any time, for injury or damage to myself, my dog(s), my property and/or my guests, their dogs and property, and assume all risks thereof.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
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Thank you for taking the time to fill out this questionnaire, it is very important to the treatment of your dog's issues.
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