Behavior History Form
Christi Chapman, CDT
Form created by Janine Allen, CPDT-KA, modified a bit, and used here with her permission
I am filling out this form for:
Myself and my dog
My family and our dog
A family member and their dog who live with me, and I want to gift them with training
A friend or family member and their dog who do not live with me, but I want to gift them with training
A friend or family member who does not have access to a computer and wants to speak with a trainer
Owner Name (or your name if you are filling out the form for somebody else)
First Name
Last Name
Owner Name (for spouse or second owner of dog)
First Name
Last Name
Email (your email if filling out for somebody else)
example@example.com
Email for second owner
example@example.com
Phone Number (your phone number if filling out for somebody else)
-
Area Code
Phone Number
May I text you at the above phone number?
Yes
No
Phone Number for second owner
-
Area Code
Phone Number
May I text you at the above phone number?
Yes
No
Address (where the dog and owner who will receive training live)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your availability for meeting times? Please choose any that apply.
Weekdays between 10am and 2pm
Weekday evenings between 5pm and 8pm
Saturdays 10am-12pm
Saturdays 12pm-7pm
Sundays 12pm -7pm
Please list the first name and age of all family/household members who will be participating in training. This information helps me to prepare age appropriate materials and lessons for each person involved.
Please add any medical or physical limitations you might have that I should be aware of. I want to be able to help you be safe when working with your dog!
Can you receive digital lesson plans and materials on a computer or device, and are you able to print them off?
Yes, I can receive and print lessons and materials.
I can receive and view lessons and materials but not print.
No, I do not have a device or printer.
I suffer from chemical reactivity to certain things. Please check the box next to these products if you use any of them inside of your home. This helps me to prepare so I don't react. We may need to meet outdoors or at an alternate location.
Cigarettes/Cigars/any other tobacco smoking device
Any type of vaping devices
Candles (such as Yankee candles or Scentsy types) 3
Outlet type diffusers (Scentsy/Glade/Oust/etc.)
Spray Air Fresheners (Febreeze/Glade/Oust/Lysol/etc.)
Dog’s name
Dog breed or “type”
Border Collie or herding mix
Dog’s approximate age or date of birth
Dog’s weight
Dog’s gender
Male intact
Male neutered
Female intact
Female neutered
Age of dog when adopted or purchased.
How did you obtain your dog? Please provide the name of the breeder, rescue or shelter if applicable.
Please list any medications your dog takes.
Does your dog have any medical conditions?
Epilepsy, Addison’s, Cushing’s, etc.
Please list any current or past medical conditions which may affect dog’s movement.
Surgeries, fractures, arthritis, etc.
Briefly describe your dog’s personality
How would your dog describe you?
How do you think your dog perceives you?
How does your dog get along with the other people in your home?
How does your dog get along with the other pets in your home?
How would your dog describe HIS daily life in your home?
Exciting? Calm? Boring? Purposeful? Chaotic? Frustrating?
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Main Concerns
What challenges are you having with your dog?
What do you think is the reason for your dog’s problem?
Describe the severity of the problem.
Mild
Moderate
Severe
What age was your dog when the problem started.
Describe any changes in the home or your routine when the problem first started.
How often does the problem occur?
What has been done so far to try and correct the problem?
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Training
What are your immediate training goals?
Do you have long term training objectives with your dog, and if so, what are they?
Describe any obedience training and how your dog responded.
What requests does your dog respond to?
Sit - always
Sit - usually
Sit - when my dog feels like it
Down - always
Down - usually
Down - when my dog feels like it
Walks on leash without pulling - always
Walks on leash without pulling - usually
Walks on leash without pulling - when my dog feels like it
Waits at door
Loads up in vehicle
Recall (comes when called) - always
Recall - usually
Recall - when my dog feels like it
Please indicate which of the following you have tried.
Gentle leader, halti, head halter
Electronic bark collar
Electronic training collar
Prong collar
Citronella collar
Buckle collar
Harness
Treat training
Clicker training
Which collar or training listed above worked best with your dog?
DId you feel most in control using treats, electronic collar, clicker training, etc.?
Which of the following will cause your dog to become distracted and lose focus from you?
Dogs
People
Birds or other animals
Noises or sounds
Cars
Bicycles, motorcycles, skateboards
Anything that moves
General fear of things in the environment
Reflections or lights
Is your dog crate trained?
Yes
No
Crate? Never!
In the past but no longer use it
Which family members have the most success in getting your dog to listen?
Why do you think they are successful? Why are others not so successful?
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Nutrition, Exercise, and Play
Types/brands of food you feed and quantity.
Purina kibble, Nature’s Variety frozen raw, three cups twice a day, etc.
What is your dog’s feeding schedule?
Time of day, food left out all day, etc.
When do you give treats and how many per day?
What type/brand of treats do you give?
Do you give your dog chews such as hooves, horns, rawhide, antlers, bully sticks, greenies, etc.?
Describe the amount, type and frequency of exercise and play your dog engages in daily.
What is your dog’s reaction to being left alone?
Calm
Worried
Barks
Whines
Cries
Paces
Destructive
Self injurious behavior (dog breaks teeth on crate, chews or licks on appendages to the point of bleeding or hair loss, paws at doors until bloody or rips nails, breaks windows, etc.)
If you chose destructive on the list, please give examples of the destructive behavior.
Example: My dog has jumped through a glass window after shredding the pillows and pawing at the doors.
If you checked self injurious behavior, please explain further here and give examples.
Example: My dog has jumped though windows multiple times, breaking the glass and getting severely cut! or My dog licks all the hair off of his legs and chews on his tail until it is bloody.
How long does the reaction last?
The entire time he is alone
Just a few minutes
Off and on while alone
Don’t know
What is your dog’s reaction to your return?
Happy and excited
Barking
Jumping
Urinating
Happy and calm
Where does your dog sleep at night?
Loose in the house
Confined to a room
Confined to a crate or a pen
On my bed
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Reactive Behavior
Please check if your dog reacts aggressively or threateningly in any of the following situations:
Being touched
During grooming
While eating
While chewing on objects or playing with toys
During punishment or discipline
When people enter the home or yard
When dogs enter the home or yard
If you checked any of the boxes above, how do YOU react to your dog in this situation?
Give a command? Move dog to another location? Grab collar?
Please check if your dog dislikes any of the following:
Car rides
Grooming or bathing
Nail trims
Cleaning or handling of ears
Touching feet
Being lifted
Touching head
Grasping collar
If you checked any of the boxes above, how do you react if your dog dislikes something?
Stop doing it? Give Treats? Keep doing it until your dog settles?
Has your dog ever bitten hard enough to break the skin or cause injury?
Yes, just once
Yes, more than once
No, just grazed the skin
My dog has snapped but not made contact
My dog has never bitten
When does your dog bark?
When left alone
When confined or crated
When someone is at the door
When meeting new dogs
When meeting new people
When in the car
When he wants to be let in or out
When he wants attention
When he sees something new
How do YOU react when your dog barks?
Say “no”? Leash your dog? Tell the dog to sit? Give treats?
Does your dog exhibit any of the following?
Urinates when excited
Fear of noises (thunder, cars, fireworks, etc.)
Shy or timid in new situations
Shy around new people
Shy around new dogs
Shy around men
Shy around children
If you checked any of the above boxes, how do YOU react to your dog in these situations?
Put dog on a leash? Move him away? Talk him through it?
How does your dog react to other animals or strangers ON your property?
How does your dog react to other animals or strangers OFF your property?
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Finished- almost!
What are all of the wonderful and good things about your dog?
You obviously love your dog enough to fill out this long form so brag a bit!
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
You are all done! Please hit the submit button. Once I have had a chance to review this form, I will contact you to discuss options and schedule an appointment. Thank you!
Christi Chapman, Professional Dog Trainer
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