Canine History Form
Before beginning, please be prepared to upload copies of vaccination records (scanned or photo).
Who referred you to us?
*
Owner Information
Primary Owner/Primary Contact Name:
*
First Name
Last Name
Other Legal Owner(s):
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
House color and parking instructions (for home visits):
Phone Number:
*
-
Area Code
Phone Number
Other Phone Number:
-
Area Code
Phone Number
Email Address:
*
example@example.com
Other Email Address:
example@example.com
What is your occupation?
Pet Information
Dog's Name:
*
Breed/Breed Mix:
*
Current Age:
*
Sex:
*
Male
Neutered Male
Female
Spayed Female
How long have you had this dog?
*
Where did you get this dog?
*
List anything you know about pet's life prior to living with you:
*
Behavior History
Below, please briefly list the specific behavior concerns you would like to resolve:
*
When did you first notice the concerning behaviors starting?
*
Does anything happen right before the concerning behavior (e.g.: doorbell rings, as soon as he sees another dog, etc)
*
How often do the most concerning behaviors occur?
*
Once or twice/day
Several times/day
Once or twice/week
Several times/week
Once or twice/month
Several times/month
Randomly
Only in specific situations
So far, only once or twice
Other
Are you prepared to work for several months or more to address your concerns?
*
Yes!
I can't do that
Uncertain/undecided
Have you considered other options, should this problem not be resolvable to your satisfaction?
*
Giving up the pet is not an option
I have/may consider giving up my pet
Uncertain/undecided
What are your goals for this pet's behavior?
*
Family Members
Please list all people (other than those already listed) who currently or recently lived with, or frequently interact with this pet.
*
Configurable list
*
Training History
How do you tell this dog he/she is being bad?
*
Physical (spanking, nose tap, etc)
Verbal (Scold, No!, Ah Ah, Tsst, etc)
Noise (Squirt Bottle, Penny Can, Clap Hands, etc)
Leash Jerk/Pop
Electronic Collar
I Don't
Other
Type a question
*
Petting
Verbal Praise
Treats/Food
Toys/Play
I Don't Know
Other
What, if any, of the following do you currently use?
*
Choke Chain
Prong Collar
Body Harness
E-Collar
Head Halter
Neck Collar
Retractable Leash
Other
List any trainers or training schools you've worked with:
*
What have you specifically tried to resolve these problems in the past?
*
How did the behaviors change in response to what you tried above?
*
Got Worse
Got Better
No Change
Uncertain
Other
Routine
How many hours a day is the dog alone on average?
*
Describe type, amount, and intensity of exercise this dog receives:
*
Health & Nutrition
Name of your vet clinic:
*
Did your vet give you any recommendations for your concerns?
*
Date of most recent exam and notable comments:
*
Please upload your Rabies Certificate
*
Please upload any other vaccines
List any current, recent, or past injuries or illnesses:
*
List any medications or supplements, etc including heartworm, flea and tick preventative:
*
List any food or environmental allergies or sensitivities:
*
Which brand of food do you feed?
*
Describe your feeding routine (check all that apply):
*
Feed at scheduled times, finishes right away
Fill bowl at scheduled times, grazes throughout the day
Food is always available
Dry kibble
Canned
Raw or homemade food
Scraps or leftover people food
Other
Do you have pet insurance?
Yes
No
Submit
Should be Empty: