Aggression Screen

Please take your time and honestly complete this form. It will assist me in assessing your dog's behaviors so that I can develope The best possible 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 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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Any familiar adult enters the room

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Any familiar child enters the room

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Any unfamiliar adult enters the room

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Any unfamiliar child enters the room

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Any familiar adult enters your yard

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Any familiar child enters your yard

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Any unfamiliar adult enters your yard

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Any unfamiliar child enters your yard

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Any familiar adult leaves the room

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Any familiar child leaves the room

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Any unfamiliar adult leaves the room

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Any unfamiliar child leaves the room

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Any familiar adult moves or stands up quickly

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Any familiar child moves or stands up quickly

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Any unfamiliar adult moves or stands up quickly

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Any unfamiliar child moves or stands up quickly

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Any familiar animal enters your home

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Any unfamiliar animal enters your home

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Any familiar animal enters your yard

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Any 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 on the street

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

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

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When your dog is inside the house / yard and sees bicycles 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 when on leash to joggers, runners, etc.

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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 visually correct your dog, i.e. spray bottle, air horn, electric coller remote, 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.