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1 Owner infrmatin Name: Phne: Address: Dg Infrmatin Dg's Name Dg's Age : Dg's age when adpted r purchased : Sex f Dg: O Male OFemale Spay/Neuter Status: O Intact O Spayed/Neutered Breed r Type: Vaccinatins Are yur dg's vaccinatins current? Veterinarian r Veterinary Hspital with yur dg's recrds n file: Reasn fr Behavir Evaluatin What is the main prblem r cncern? Hw ften is the main prblem ccurring? Once a mnth r less N mre than nce a week Several times a week Every day Multiple times per day This prblem is increasing in Frequency Intensity Duratin Nne f the abve
2 Please check ff any additinal issues. Nt husebrken Urinates when excited r afraid Munts humps peple r bjects Jumps up Overactive Desn't settle easily Nervus r easily stressed Fearful r shy Nuisance barking Demanding/Needy Barking Chews destructively Blts thrugh pen drs Pulls n leash Desn't cme when called Unrespnsive t name r cmmands Inattentive/shrt attentin span Play biting/muthing Steals fd r bjects Guards fd, tys r bjects Guards peple Guards space r territry Aggressive tward peple Aggressive tward dgs Grwls at family members Has injured ne mre persn Has injured ne r mre dg Separatin Anxiety Other If guarding, please explain (what and when): If aggressive, please explain (what and when): If has bitten r caused injury t a persn, please explain (wh, when, where, extent f injuries): If has bitten r caused injury t anther dg, please explain (wh, when, where, extent f injuries): If ther, please explain. Describe the mst serius incident that has s far ccurred: Describe the mst recent incident. What have yu dne t address r crrect the abve issues? (Please explain when and fr hw lng.)
3 Were these methds effective? (Please explain.) What f the abve are yur mst urgent pririties? What are yur lng-term gals fr yur dg? Husehld Infrmatin Hw many adults reside in yur husehld? (Please list.) Hw many children? (Please list names and ages.) What ther pets d yu wn? Hw many visitrs cme t the hme n average each week? Is yur dg's interactin with any f the abve a cncern? (Please explain.) Is this yur first dg? If nt, please list frmer dgs by breed. In what style f hme d yu live? (Huse r apartment, hw many stries, etc.) D yu have a yard? If yes, is it securely fenced? D yu tie yur dg ut? Hw much time des yur dg spend in the yard unattended?
4 Where des yur dg sleep? D yu crate yur dg? If s, when and hw des he tlerate it? D yu ever cnfine yur dg t a rm r area f the huse? Hw much time des yur dg spend lse in the hme unattended? General Histry Hw did yu chse yur current dg? Where did yu purchase r adpt? D yu knw r were yu given infrmatin regarding yur dg's parents, littermates, r early histry? Is yur dg scial with new peple? Is yur dg scial with ther dgs? Hw much scial interactin with ther dgs has yur dg had, either n-leash r ff? D yu visit dg parks r send yur dg t daycare? If s, where and hw ften? Describe yur dg's play style r manner f interactin with ther dgs? Describe the methds yu've used t train yur dg in the past, including a list f training equipment yur dg is familiar with. If yu have wrked with a trainer r behavirist previusly, describe what that entailed.
5 Check ff any cmmands r skills yur dg knws r has. Sit Dwn Stay Cme Heel Off Leave It Lse-leash Manners Tuch Watch Me Out Drp Free Okay Hand Signals Other cmmands r skills If hand signals r ther cmmands, please list. Health Histry What d yu feed yur dg, hw ften, and hw much? Is yur dg under r verweight? Please list any current r recent medicatins. If current, please give dsage and schedule. Has yur dg been diagnsed with, r d yu suspect, any medical cnditins? Has yur dg ever suffered any serius injuries? (Please explain.) Aggressin Histry If yur dg has bitten, was it reprted? Please give details. Was skin brken, r medical treatment required? Please give details.
6 When did yu first ntice signs f aggressin. Please explain. Check any knwn r suspected aggressin triggers. Stranger appraching Stranger passing Direct r heavy eye-cntact Apprach r physical cntact while eating Apprach r physical cntact while resting Apprach r physical cntact while having a ty Verbal crrectin Leash crrectin Other physical crrectin r punishment Apprach r presence f children r infants Nne What are yur expectatins r gals with this behaviral cnsult? Is there anything else in yur dg's histry that we shuld knw?
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