My Dog's History Form
Street Address Line 2
State / Province
Postal / Zip Code
Other Household Members
Name of Dog
Sex of Dog
Is your dog neutered/spayed? If yes, at what age?
How old was the dog at adoption/purchase?
Did the dog have previous owners? If yes, please add any known details:
Do you know why the dog was relinquished?
How long have you owned this dog?
How did you obtain this dog?
Breeder (small scale breeder/backyard)
Friend or family member
What is this dog's primary purpose?
Show and/or sports
When was the dog's last health exam?
Is the dog fully vaccinated? If so, please provide dates.
Dog your dog have medical issues? If yes, please describe.
Is your dog taking any prescription medications? If yes, please list:
Is your dog taking any supplements? If yes, please list:
What brand of food do you feed your dog? Please include daily rations, as well as treats, etc.
Does your dog have any known food allergies? If yes, please list:
How does your dog get its exercise?
Loose in yard
Fenced in kennel or run
Walked on leash
Walked without leash
Formal exercise plan
Mental stimulation games
How many daily play sessions does your dog have on a normal day? Please describe.
How many formal training sessions does your dog receive on a normal day? Please describe.
How is your dog kept when you leave the house?
Loose in house
Outdoor kennel or run
Indoor kennel or run
Crate indoors (garage)
Crate (inside home)
Confined by gate or door to specific area
What type of dwelling does the dog inhabit?
Apartment-type without patio
Apartment-type with patio
House with small yard
House with large yard
House with dog run
House with acreage
Have there been any significant life changes in the past 6-12 months?
Move to new location
Death in the family
Divorce/separation/new partner or roommate
New job/schedule change
Why did you choose this specific dog?
Is this your first dog?
What is your dog's prior known training history?
Does the dog hold any titles?
How does the dog respond to basic cues?
OK (needs work)
Heel/Loose Leash Walking
Leave It/Drop it
Watch Me/Eye Contact
Please list all people living in the dog's household (include temporary guests)
Please list all animals living in the dog's household (include current fosters).
If any of these other pets have medical issues, please describe:
If any of these other pets have behavioral issues, please describe:
Please list your dog's most urgent undesirable behaviors:
Have you considered rehoming your pet due to behavioral issues?
Have you considered euthanizing your pet due to behavioral issues?
Have you seen your veterinarian regarding these behavioral issues? If yes, please explain outcome:
Has your dog bitten another dog? If yes, please explain:
Has your dog bitten a human? If yes, please explain:
Was there any legal action as a result of any bite to dog and/or human? If yes, please explain:
Is your dog sensitive to sounds? If yes, please mark all that apply:
Noises outside the home
Barking neighborhood dogs
Noises at the front door
Please mark any severe reactions to sound.
What steps have been taken to alter your dog's undesirable behavior?
Stare or "evil eye"
Grab and shake jowls
Get a dog companion
Blow in dog's face
Kong or puzzle feeder
Metal chain "choke" collar
Front clip harness
Dominant dog collar
Anti-bark collar (citronella)
Throw cans or chains
Water bottle spray
Air or fog horn
Increase body pressure (stand over dog)
Slap dog with leash
Rub dog's nose in item
Hold dog in down position
Growl at dog
Raise voice or yell at dog
Use No, eh eh, or tsssk
No reward marker
Enforced long downs/stays
Place dog in crate
Place dog in prolonged time out
Praise/food for good behavior
Board and train at commercial kennel
Board and train at trainer's home
String dog up in air by collar
Scat mats or other electronic devices
Bitter Apple Spray
White noise machine
Desensitization and counter conditioning
Dominance reducing strategies
Describe any other training methods used to treat behavior problems. If you feel anything worked in particular (or was detrimental), please explain:
Have you noticed any of the following behaviors in your dog?
Eating other inappropriate items
Chewing and other destructive behaviors
Has there been any change in the environment you feel is associated with the problem behaviors? If yes, please describe:
Is there any time of day the problems are more intense? If yes, please describe:
Is there any particular person and/or pet associated with the behavior? If yes, please describe:
Is the dog responsive to cues or their name when in the middle of behavior? If yes, please describe:
Can you stop the behavior by interruption or calling the dog to you? If yes, please describe:
Is there a particular location where the behavior occurs? If yes, please describe:
Can you identify anything that may trigger the behavior?
Is there anything else we need to know about your dog and its behavior?
What are your goals with training/behavior modification?
What are your expectations of the training process?
How much time and effort are you reasonably able to invest in training your dog?
Do you have any specific questions you would like answered in the consult?
Please use this section to add anything else you would like us to know.
How did you hear about Broadway Dog Training?
Thank you very much for completing this questionnaire!
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