Updated Behavior consult form

Behavior Consultation Form
Date of Appointment
Time of Appointment
Location of Appointment

At Lucky DogAt client's homeOther
How did you first hear about us?
Your Full Name

First NameLast Name
Dog's Name
How long have you had this dog?
How old was your dog when you got him or her?
If you have already created an account with your info and your dog's, feel free to leave blank the following information.
Home Number

Area CodePhone Number
Email Address
Cell phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Dog's Breed
Gender

MaleMale/neuteredFemaleFemale/spayed
Birth Date

MonthDayYear
Who is your regular veterinarian?
Dr.
Clinic Name
Phone Number

Area CodePhone Number
City
Reason for Consultation
What is the main behavior problem or complaint? Please be specific about the issues and behaviors you are observing.
Additional problems (please list and try to be specific)
How frequently does the problem (or problems) occur (how many times daily, weekly or monthly)? Please list below.
Main Problem and frequency:
Other problem and frequency::
Any additional problem and frequency:
My dog is fearful, reactive or aggressive when: (check all that apply)*

NeverReached forPushed/pulledLeash/collar put on/taken offCorrectedLiftedEating/food/bonesTouchedHuggedOn walksPlaying with toysSees other dogsSees childrenSees strangersSees bikes/skateboards/carsSees anyone from the house windowFamiliar visitors come to my homeUnfamiliar people come to the homeOn leashOff leashOther
My dog is fearful, aggressive or reactive toward (check all that apply)*

DogsUnfamiliar adultsFamiliar adultsUnfamiliar childrenFamiliar childrenother animalsmoving things/objectsn/a
This is how my dog shows fear, reactivity, or aggression*

BarksSnapsPullsSnarlsRaises hacklesLungesBites/tries to biteTries to run away or hideJumps upGrowlsNipsStaresChasesn/aOther
I have used the following to correct the behavior. (Please check all you've tried whether they have worked or not)*

Stare downLoud noiseHead collar (Gentle Leader/Halti)Citronella collarShake or throw can or other objectWater pistol/sprayIncrease exercise/playDecrease exercise/playChoke collarCrateKnee/hitTreatsPraiseHang by collarForce dog on his or her sideProng collarharnessShock collarGrab scruffMuzzleTime outYellingn/aOther
At what distance does your dog react to stimuli (dogs, people, things)?
How far away does the stimulus have to be before your dog relaxes?
If your dog has an issue with guests, where is your dog when you have visitors?
Has your dog ever bitten or tried to bite another dog or a person (including yourself)?

YesNo
If so, please describe the incident.
What is your main goal for private training? What outcome are you hoping for?
Chronology of the Behavior Problem
How old was your dog when you first noticed the main problem?
When did it first become a serious concern?
Has this problem changed in frequency? (please describe)
Has this problem changed in intensity? (please describe)
Has this problem otherwise changed?
Describe several examples in detail:
1. Most recent incident: (Please list date and describe your dog's behavior)
2. Second to last incident: (Please list date and describe)
3. Third to last incident: (Please list date and describe)
Other significant incidents:
Please list the people, including yourself, living in your household. Please include ages of children.
Please list all the other animals in the household that this dog interacts with. Include name, species, breed, sex, age obtained and age now. List them in the order that you got them please.
What is your dog's relationship to the other animals (ex. friendly, hostile, fearful)?
Has anything changed recently in your dog's environment or living condition (such as owner illness, move, travel, construction, etc.)?
Dog's background
Where did you get this dog?

Humane society/County facility/rescueBreeder from adBreeder from referralPet storeFriend/acquaintanceStrayOther
Why did you choose this breed?
If known, how many littermates:
If applicable, describe your dog's behavior as a puppy.
Do you have any information about the behavior of other dogs in the same litter?
If you met the parents, please describe their behavior.
Has this dog had any other owners, and if yes, how many?
If this dog had other owners, describe why it was given up.
Have you had other dogs?

YesNo
Please describe a typical 24-hour day in your dog's life:
Where is your dog kept the majority of the time?

My dog is kept in a fenced yardMy dog is tied outsideMy dog runs freeMy dog is kept within an electric fenceMy dog spends most of his/her time in the house
Where is your dog when alone in the house (a specific room, crate, etc.)?
In a typical day, how long is your dog left alone?
How do you exercise your dog?
How do you play with your dog?
Is your dog housetrained?

YesNo
If your dog eliminates in the house please specify, urination or defecation. and the frequency.
Does your dog like to play with toys? What types of toys/games are his favorites?
How often do you feed your dog? What brand and type of food do you feed?
How do you feed your dog? (Check as many as apply.)

Free feeding (I leave the food down)I feed my dog's meals on a scheduleI feed out of a bowlI feed out of a food toyOther
Obedience Training
What obedience training has your dog had?

NonePrivate trainerTrained by meStarted an obedience class but did not finishGraduated one classGraduated two or more classesCurrently attends class for obedience or a dog sportParticipates in canine events such as dog agility, hunting, tracking, etc.Other
How old was the dog when training started?
Who in the family is the primary trainer?
Does your dog jump up on you or others without permission?

YesNoI want to change this behavior.
Does your dog paw at you or at others?

YesNoI want to change this behavior.
Does your dog bark at you for attention?

YesNoI want to change this behavior
Does your dog bark at other things regularly?
What is your dog's activity level in general (Choose one)

LowAverageHighExcessive
Is there any other information you would like us to know?
Medical History
Please list any medical issues, current or recently resolved.
Please describe any medications your dog is on and for what problem.
Date of the most recent rabies vaccination and whether it is a one year or three year vaccine.
Should be Empty:

Behavior Consultation Form