Behavior Survey

Behavior Survey

This form must be completed and submitted prior to consult/first appointment.
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 or behavior modification plan to improve/change these behaviors.
Date*

MonthDayYear
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*
Comment:
Hug Your Dog*
Comment:
Kiss Your Dog*
Comment:
Lift Your Dog*
Comment:
Stare at your dog*
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Bend over your dog*
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Reach TOWARDS your dog's face/head*
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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*
Comment:
Touch your dog's face*
Comment:
You approach furniture / bed*
Comment:
Push / pull from furniture / bed*
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Disturb while resting / sleeping*
Comment:
Try to put on collar / harness*
Comment:
Try to take off collar / harness*
Comment:
Try to put on leash*
Comment:
Try to take off leash*
Comment:
Restrain your dog by holding the collar / harness / leash*
Comment:
Resource Guarding
Approach while eating*
Comment:
Touch while eating*
Comment:
Take food away while eating*
Comment:
Approach near treat / toy*
Comment:
Touch treat / toy*
Comment:
Take treat / toy*
Comment:
Approach water dish*
Comment:
Touch water dish*
Comment:
Take away water dish*
Comment:
Reaction to ANY object in your dog's possession*
Comment:
Does Your Dog Guard Any Person in Your Household or Its Trusted Circle? If YES, explain who and under what circumstances*
Grooming Your Dog
Bathe your dog*
Comment:
Towel dry your dog*
Comment:
Blow dry your dog*
Comment:
Brush / comb your dog*
Comment:
Trim nails*
Comment:
Interactions with People in Your Home / Yard
A FAMILIAR ADULT enters the room*
Comment:
A FAMILIAR CHILD enters the room*
Comment:
A FAMILIAR ADULT moves or stands up quickly*
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A FAMILIAR CHILD moves or stands up quickly*
Comment:
A FAMILIAR ADULT leaves the room*
Comment:
A FAMILIAR CHILD leaves the room*
Comment:
A FAMILIAR ADULT enters your yard*
Comment:
A FAMILIAR CHILD enters your yard*
Comment:
An UNKNOWN / LESS FAMILIAR ADULT enters the room*
Comment:
An UNKNOWN / LESS FAMILIAR CHILD enters the room*
Comment:
An UNKNOWN / LESS FAMILIAR ADULT moves or stands up quickly*
Comment:
An UNKNOWN / LESS FAMILIAR CHILD moves or stands up quickly*
Comment:
An UNKNOWN / LESS FAMILIAR ADULT leaves the room*
Comment:
An UNKNOWN / LESS FAMILIAR CHILD leaves the room*
Comment:
An UNKNOWN / LESS FAMILIAR ADULT enters your yard*
Comment:
An UNKNOWN / LESS FAMILIAR CHILD enters your yard*
Comment:
Response to babies / toddlers*
Comment:
Interaction with Animals in Your Home / Yard
A FAMILIAR ANIMAL enters your home*
Comment:
An UNFAMILIAR ANIMAL enters your home*
Comment:
A FAMILIAR ANIMAL enters your yard*
Comment:
An UNFAMILAIR ANIMAL enters your yard*
Comment:
When your dog is inside the house / yard and sees people on the street*
Comment:
When your dog is inside the house / yard and sees dogs on the street*
Comment:
When your dog is inside the house / yard and sees cars, motorcycles, trucks, etc. on the street*
Comment:
When your dog is inside the house / yard and sees skateboards, bicycles, etc. on the street*
Comment:
Your dog's reaction to delivery people, mail person, etc.*
Comment:
Interactions & Environments Out & About
Your Dog & Your Vehicle*
Comment:
When your dog is in the car at a drive-thru, tollbooth, gas station, etc.*
Comment:
Interactions When On Leash
A FAMILIAR ADULT approaches when you're with your dog ON LEASH*
Comment:
AN UNFAMILIAR ADULT approaches when you're with your dog when ON LEASH*
Comment:
A FAMILIAR CHILD approaches when you're with your dog ON LEASH*
Comment:
AN UNFAMILIAR CHILD approaches when you're with your dog when ON LEASH*
Comment:
A LEASHED FAMILIAR DOG approaches when you're with your dog ON LEASH*
Comment:
AN UNLEASHED FAMILIAR DOG approaches when you're with your dog ON LEASH*
Comment:
Your dog's reaction to Runners, Joggers, Walkers, etc. when On Leash*
Comment:
Your dog's reaction to Vehicles when ON LEASH*
Comment:
Your dog's reaction to Bicycles, Skateboards, Scooters, etc. ON LEASH*
Comment:
Interactions When Off Leash
A FAMILAIR ADULT approaches when you're with your dog OFF LEASH*
Comment:
AN UNFAMILIAR ADULT approaches when you're with your dog OFF LEASH*
Comment:
A FAMILIAR CHILD approaches when you're with your dog OFF LEASH*
Comment:
AN UNFAMILIAR CHILD approaches when you're with your dog OFF LEASH*
Comment:
A LEASHED FAMILIAR DOG approaches when you're with your dog OFF LEASH*
Comment:
AN UNLEASHED FAMILIAR DOG approaches when you're with your dog OFF LEASH*
Comment:
A LEASHED UNFAMILIAR DOG approaches when you're with your dog OFF LEASH*
Comment:
AN UNLEASHED UNFAMILIAR DOG approaches when you're with your dog OFF LEASH*
Comment:
Other Circumstances
Your dog's reaction to thunderstorms*
Comment:
Your dog's reaction to fireworks*
Comment:
Your dog's reaction to sudden noises*
Comment:
Your dog's reaction to sudden movement*
Comment:
Does your dog have negative behaviors towards specific dogs, breeds, size, colorings, etc.?
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*
Comment:
Reaction when you physically correct your dog*
Comment:
Reaction when you correct your dog, i.e. spray bottle, air horn, electric collar, etc.*
Comment:
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.
MonthDayYear
Date
Should be Empty:

Behavior Survey

Resource Guarding

Grooming Your Dog

Interactions with People in Your Home / Yard

Interaction with Animals in Your Home / Yard

Interactions & Environments Out & About

Interactions When On Leash

Interactions When Off Leash

Other Circumstances