Client Information

Client and Canine Information Questionnaire

This form must be completed and submitted prior to consult/first appointment.
I greatly appreciate you taking the time to complete this questionnaire. The information will be used solely to review your dog’s history and to help me prepare a plan for training or behavior modification.

Please review this entire questionnaire first, then go back and answer the questions as thoroughly as possible. If there was an incident (such as a bite), please ask anyone who witnessed the bite incident for their input as well.

The information contained herein will only be shared with another trainer, veterinarian, veterinary specialist or veterinary behaviorist with your permission.
Client Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *
Cell Phone *
Email *
Additional Household Members
Name

First Name Last Name
Age
Contact Info:
Name

First Name Last Name
Age
Contact Info:
Name

First Name Last Name
Age
Name

First Name Last Name
Age
Name

First Name Last Name
Age
Pet Information
Dog's Name
Breed / Mix
Color / Markings
Age
Weight
Gender
Is Your Dog

Spayed Neutered
Other Pets in Your Home: Please provide above information about each.
Tell Me ABout Your Dog
Why did you decide to get your dog?
Have you owned other dogs? If so, what type and when?
Where did you acquire your dog from?
When did you acquire your dog?
If acquired from a breeder, did you meet one or both of the breeding pair and what were they like?
If acquired from a breeder, did you take your dog home or was your dog shipped to you? If shipped, by what method, i.e. ground or sir transport?
If adopted from a shelter or rescue group, please provide the name of the organization and a point of contact
If you've adopted your dog, what is your dog's history prior to your adoption?
Medical Information:
Name, Address and Phone number of your veterinary service:
Current health issues and medications:
Past medical conditions and treatments:
Past or current medications and cause:
Dietary Information
Does you dog have any food allergies? If yes, please explain:
What type and brand of food do you feed your dog?
How many times a day do you feed your dog and how much each time?
What types of chews and treats does your dog like?
General Information
Is Your Dog Reliably Housetrained

Yes No
Does Your Dog Eliminate Outside?

Yes No
Is Your Dog Crate Trained?

Yes No Somewhat
Do You Have a Doggy Door?

Yes No
What type of exercise does your dog get and how often?
Does your dog have a primary person? if so, who is it?
Is your dog frightened of any household members? Please specify who and any possible reasons why
Are any household members frightened of your dog? Please specify who and why.
What type of home do you live in?
Does your home have a fenced in yard? if so, what areas of your yard are fenced and what type of fence?
When no one is home, is your dog:

Able to go in and out on it's own Confined indoors to a crate Confined indoors to a room Confined outdoors to a kennel or dog run Tethered outdoors
If your dog is confined when you're not at home, how long is your dog confined for?
If your dog is confined when you're not at home, why is your dog confined?
Where does your dog sleep at night?
Does your dog get along with your other pets? If not, please specify any conflicts
What are your dogs favorite toys and games?
List five things you like about your dog
List 5 things your dog looks forward to every day (not including being fed):
List 5 things you don't like about your dog
What kinds of socialization with other dogs has your dog had?
What kinds of environments has your dog been exposed to?
Life Skills & Manners
When you walk your dog, do you use:

Flat collar Prong collar Choker collar Martingale collar Electric collar Standard body harness Front clip, no pull body harness Head halter Standard leash Retractable leash No leash
Please list the organizations or instructors that you've had for prior training and when that was
What type of training has your participated in?

None Puppy kindergarten Puppy basics Beginner basics Intermediate skills Advanced skills Agility Herding Canine Good Citizen Therapy dog Service dog Individualized Group classes Behavior modification
What types of training methods have you or your instructors used?

Leash corrections Prong or choker collar training Alpha rolls Verbal corrections Physical force Electric or shock collar training Spray bottle Sound aversion (loud noise) Scat mats Holding the mouth closed Hitting / striking Grabbing / pinching the scruff of the neck Staring Growling Throwing bags or chains Positive Reinforcement Food/ treats Balls Games Praise
What basic skills does your dog perform reliably

Sit Down Stay Recall (Come) Walks nicely on leash Give or Drop it Leave it Go to Place Off Doesn't jump on people
Which of these inappropriate behaviors, if any, apply to your dog?

Jumps on people Steals food / objects Counter-surfs Rough play Painful play biting Bites / pulls on clothing Pulls on leash Escapes out doors / gates / yard Excessive attention seeking Digs holes in yard Eliminates in the house
Has the onset of these inappropriate behaviors coincided with any of the following changes?

Person moving out of your home The passing of a person in your household The passing of a pet in your household Recent vaccination(s) Use of physical force while training Use of physical force when correcting inappropriate behavior Past abuse or neglect New person / baby in your home Change in someone's work hours New medication Change in medication New pet in home Change in exercise routine Change in health Recent surgery / treatment Change in diet Change in treats / chews Prior behavior modification techniques Environmental change (construction, etc.) Move to a new home / location Sent your dog away for training Spending less time with your dog
What steps, if any, have you taken to address any of the inappropriate behaviors? Please be specific
If you have addressed any of the inappropriate behaviors, did your dog's behavior:

Stay the same Improve somewhat Improve greatly Became somewhat worse Became much worse
Fearful, Aggressive, Reactive Behaviors
Which of these aggressive, reactive and/or fearful behaviors, if any, apply to your dog?

Aggressive towards family members Aggressive towards strangers Aggressive towards visitors to your home Aggressive towards family pets Aggressive towards other dogs Aggressive towards other animals Aggressive at vet office Aggressive at groomers Aggressive when petted / handled / picked up Excessive vocalization when alone Excessive vocalization when people are home Guards toys Guards people Guards food Guards bed / couch Has accidents in the house Destructive when left alone Darts out doors / gates Always wants attention Separation anxiety Startles easily Always on edge Fearful of noises Fearful of sudden movement Fearful of storms / fireworks
Does your dog display any of these behaviors when nervous / anxious / fearful / stressed?

Lots of lip licking Multiple yawns Turns away Makes itself smaller Paces Growls Avoids eye contact Hides Barks Aggresses forward Nips or bites from behind Hackles raised Excessive barking Is unable to settle or relax Shows teeth / snarls Spins in circles Chases shadows or reflections Chases own tail, biting at it Avoids physical contact Seeks physical contact from trusted person
Has the onset of the aggressive, reactive, fearful or other changes in behaviors coincided with any of the following changes?

Person moving out of your home The passing of a person in your household The passing of a pet in your household Recent vaccination(s) Use of physical force while training Use of physical force when correcting inappropriate behavior Past abuse or neglect New person / baby in your home Change in someone's work hours New medication Change in medication New pet in home Change in exercise routine Change in health Recent surgery / treatment Change in diet Change in treats / chews Prior behavior modification techniques Environmental change (construction, etc.) Move to a new home / location Sent your dog away for training Spending less time with your dog
What steps, if any, have you taken to address the aggressive, reactive or fearful behaviors? Please be specific
If you have addressed any of the aggressive, reactive or fearful behaviors, did your dog's behavior:

Stay the same Improve somewhat Improve greatly Became somewhat worse Became much worse
Bite Incident(s)

This does NOT include the appropriate use of your dog's mouth in the course of appropriate play

If your dog has threatened and/or bitten a person or animal, whether or not there was an injury, you MUST complete a Bite Event Questionnaire for each incident.

Air-snapping, grabbing another dog without inflicting injury, a nip that doesn't break skin are just some examples of what you may not consider a bite, but they are.
Help for Your Dog
List in order of importance the things you'd like help with:
Which of the following best describes your feelings about your dog's behavior?

The problem is not serious but I am curious about what you would suggest The problem is not serious but I would like to change the behavior The problem is somewhat serious and I'd like to change it but if it remains unchanged, I can live with it The problem is very serious. I'd like to change but if it remains unchanged I will keep my dog anyway The problem is extremely serious. I would like it to change but if it remains unchanged, I will relinquish my dog or euthanize my dog
Tell me anything else you feel it is important for me to know about your dog:
How were you referred you to me?
By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I further agree that my signature on this document is as valid as if I signed the document in writing.
Please visit my website to learn more about my training, education, methods, skills, credentials and history

www.theinnerdog.com
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Client and Canine Information Questionnaire