Client Information

Client and Canine Information

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.

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

CityState / Province

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

First NameLast Name
Age
Cell Phone*
Email*
example@example.com
Name

First NameLast Name
Age
Name

First NameLast Name
Age
Name

First NameLast Name
Age
Name

First NameLast Name
Age
Pet Information
Dog's Name
Breed / Mix
Color / Markings
Age
Weight
Gender
Is Your Dog Spayed or Neutered

YesNoSpayedNeutered
Is Your Dog Up to Date on Rabies Vaccine

YesNo
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

YesNo
Does Your Dog Eliminate Outside?

YesNo
Is Your Dog Crate Trained?

YesNoSomewhat
Do You Have a Doggy Door?

YesNo
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 ownConfined indoors to a crateConfined indoors to a roomConfined outdoors to a kennel or dog runTethered 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 collarProng collarChoker collarMartingale collarElectric collarStandard body harnessFront clip, no pull body harnessHead halterStandard leashRetractable leashNo 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?

NonePuppy kindergartenPuppy basicsBeginner basicsIntermediate skillsAdvanced skillsAgilityHerdingCanine Good CitizenTherapy dogService dogIndividualizedGroup classesBehavior modificationOther
What types of training methods have you or your instructors used?

Leash correctionsProng or choker collar trainingAlpha rollsVerbal correctionsPhysical forceElectric or shock collar trainingSpray bottleSound aversion (loud noise)Scat matsHolding the mouth closedHitting / strikingGrabbing / pinching the scruff of the neckStaringGrowlingThrowing bags or chainsPositive ReinforcementFood/ treatsBallsGamesPraiseOther
What basic skills does your dog perform reliably

SitDownStayRecall (Come)Walks nicely on leashGive or Drop itLeave itGo to PlaceOffDoesn't jump on peopleOther
Which of these inappropriate behaviors, if any, apply to your dog?

Jumps on peopleSteals food / objectsCounter-surfsRough playPainful play bitingBites / pulls on clothingPulls on leashEscapes out doors / gates / yardExcessive attention seekingDigs holes in yardEliminates in the houseOther
Has the onset of these inappropriate behaviors coincided with any of the following changes?

Person moving out of your homeThe passing of a person in your householdThe passing of a pet in your householdRecent vaccination(s)Use of physical force while trainingUse of physical force when correcting inappropriate behaviorPast abuse or neglectNew person / baby in your homeChange in someone's work hoursNew medicationChange in medicationNew pet in homeChange in exercise routineChange in healthRecent surgery / treatmentChange in dietChange in treats / chewsPrior behavior modification techniquesEnvironmental change (construction, etc.)Move to a new home / locationSent your dog away for trainingSpending less time with your dogOther
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 sameImprove somewhatImprove greatlyBecame somewhat worseBecame much worseOther
Fearful, Aggressive, Reactive Behaviors
Which of these aggressive, reactive and/or fearful behaviors, if any, apply to your dog?

Aggressive towards family membersAggressive towards strangersAggressive towards visitors to your homeAggressive towards family petsAggressive towards other dogsAggressive towards other animalsAggressive at vet officeAggressive at groomersAggressive when petted / handled / picked upExcessive vocalization when aloneExcessive vocalization when people are homeGuards toysGuards peopleGuards foodGuards bed / couchHas accidents in the houseDestructive when left aloneDarts out doors / gatesAlways wants attentionSeparation anxietyStartles easilyAlways on edgeFearful of noisesFearful of sudden movementFearful of storms / fireworksOther
Does your dog display any of these behaviors when nervous / anxious / fearful / stressed?

Lots of lip lickingMultiple yawnsTurns awayMakes itself smallerPacesGrowlsAvoids eye contactHidesBarksAggresses forwardNips or bites from behindHackles raisedExcessive barkingIs unable to settle or relaxShows teeth / snarlsSpins in circlesChases shadows or reflectionsChases own tail, biting at itAvoids physical contactSeeks physical contact from trusted personOther
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 homeThe passing of a person in your householdThe passing of a pet in your householdRecent vaccination(s)Use of physical force while trainingUse of physical force when correcting inappropriate behaviorPast abuse or neglectNew person / baby in your homeChange in someone's work hoursNew medicationChange in medicationNew pet in homeChange in exercise routineChange in healthRecent surgery / treatmentChange in dietChange in treats / chewsPrior behavior modification techniquesEnvironmental change (construction, etc.)Move to a new home / locationSent your dog away for trainingSpending less time with your dogOther
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 sameImprove somewhatImprove greatlyBecame somewhat worseBecame much worseOther
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.

Please ask anyone who witnessed the bite incident for their input as well.
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 suggestThe problem is not serious but I would like to change the behaviorThe problem is somewhat serious and I'd like to change it but if it remains unchanged, I can live with itThe problem is very serious. I'd like to change but if it remains unchanged I will keep my dog anywayThe problem is extremely serious. I would like it to change but if it remains unchanged, I will relinquish my dog or euthanize my dogOther
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