Behavior Survey

Please take your time and honestly complete this questionnaire. Your answers will assist me in assessing your dog's behaviors so that I can develope the best possible training and behavior modification plan to improve/change these behaviors.

Date

Month Day Year

Owner's Name

Dog's Name

Email

Phone

Use the drop down menu and comment box to describe your dog's reaction

Pet Your Dog

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Hug Your Dog

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Kiss Your Dog

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Lift Your Dog

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Stare at your dog

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Bend over your dog

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Reach towards your dog

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Reach over your dog's head

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Push on your dog's shoulders or back

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Touch your dog's paws / feet

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Touch your dog's tail

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Touch your dog's face

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You approach furniture / bed

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Push / pull from furniture / bed

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Disturb while resting / sleeping

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Approach while eating

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Touch while eating

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Take food away while eating

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Approach near treat / toy

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Touch treat / toy

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Take treat / toy

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Approach water dish

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Touch water dish

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Take away water dish

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Reaction to ANY object in your dog's possession

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Try to put on collar / harness

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Try to take off collar / harness

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Try to put on leash

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Try to take off leash

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Restrain your dog by holding the collar / harness

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Restrain your dog on leash

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Bathe your dog

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Towel dry your dog

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Blow dry your dog

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Brush / comb your dog

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Trim nails

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A familiar adult enters the room

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A familiar adult moves or stands up quickly

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A familiar adult leaves the room

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A familiar adult enters your yard

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An unfamiliar adult enters the room

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An unfamiliar adult moves or stands up quickly

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An unfamiliar adult leaves the room

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An unfamiliar adult enters your yard

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A familiar child enters the room

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A familiar child moves or stands up quickly

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A familiar child leaves the room

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A familiar child enters your yard

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An unfamiliar child enters the room

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An unfamiliar child moves or stands up quickly

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An unfamiliar child leaves the room

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An unfamiliar child enters your yard

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A familiar animal enters your home

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An unfamiliar animal enters your home

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A familiar animal enters your yard

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An unfamiliar animal enters your yard

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Response to babies / toddlers

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When your dog is in the car at a drive-thru, tollbooth, gas station, etc.

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Familiar adult approaches when you're with your dog on leash

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Familiar child approaches when you're with your dog on leash

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Familiar dog on leash approaches when you're with your dog on leash

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Familiar adult approaches when you're with your dog off leash

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Familiar child approaches when you're with your dog off leash

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Familiar dog on leash approaches when you're with your dog off leash

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Familiar dog off leash approaches when you're with your dog off leash

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Unfamiliar adult approaches when you're with your dog when on leash

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Unfamiliar child approaches when you're with your dog when on leash

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Unfamiliar dog on leash approaches when you're with your dog on leash

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Unfamiliar adult approaches when you're with your dog off leash

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Unfamiliar child approaches when you're with your dog off leash

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Unfamiliar dog on leash approaches when you're with your dog off leash

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Unfamiliar dog off leash approaches when you're with your dog off leash

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When your dog is inside the house / yard and sees people on the street

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When your dog is inside the house / yard and sees dogs on the street

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When your dog is inside the house / yard and sees cars, motorcycles, trucks, etc. on the street

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When your dog is inside the house / yard and sees skateboards, bicycles, etc. on the street

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Your dog's reaction to delivery people, mail person, etc.

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Your dog's reaction when on leash to vehicles

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Your dog's reaction when on leash to bicycles, skate boards, scooters, etc.

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Your dog's reaction to thunderstorms

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Your dog's reaction to fireworks

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Your dog's reaction to sudden noises

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Your dog's reaction to sudden movement

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Behavior at veterinary clinic

explain in detail

Behavior with groomer

explain in detail

Behavior with dog walker / pet sitter

explain in detail

Reaction when you verbally correct your dog

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Reaction when you physically correct your dog

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Reaction when you correct your dog, i.e. spray bottle, air horn, electric collar, etc.

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Additional Information About Your Dog's Behaviors

I know I've asked you many questions and I thank you for taking the time to complete this form. You've demonstrated a commitment to helping your dog overcome any challenges it faces and to be your dog's advocate for a better life. Your dog thanks you for being the partner it needs.

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.

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