Home Phone:
Cell Phone:
Employer's Name:
Work Phone:
Email: *
Name of preferred local pharmacy:
Phone:
Fax:
Canine's name: *
Age:
Breed:
Color:
Age when performed:
Weight:
Date and age when acquired (if known):
If Other, please explain:
Reason for obtaining this dog:
Litter size (if known):
Age when weaned (if known):
Describe your dog's personality:
If so, at what age?
How much interaction did the puppy have with people in the first year of life?
What method of house training was used?
Your reaction to mistakes during house training:
Was there any interaction with other puppies and dogs? If so, provide details:
Primary veterinarian:
Clinic name:
Phone:
Fax:
Please list the most recent set of vaccinations received and the date(s):
Referred by:
Provide medical history (infection/surgeries) and prescribed treatment:
Please explain change in eating habits:
Please explain change in drinking habits:
If so, describe the treatment and medication (if applicable):
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name, Type and Breed:
Age:
Relationship with dog (fight, play, avoid)
Name, Type and Breed:
Age:
Relationship with dog (fight, play, avoid)
Name, Type and Breed:
Age:
Relationship with dog (fight, play, avoid)
Name, Type and Breed:
Age:
Relationship with dog (fight, play, avoid)
If so, provide details (where, when, age, handler):
What types of training techniques were used?
If you were asked to leave, please explain why:
If Other, please elaborate:
If so, provide details:
If so, provide details:
How do you correct your dog when he/she misbehaves?
What types of training aids have you used (e.g., pinch collar, prong collar, electric shock)?
Brand(s) (e.g., Nutro, Eukanuba, Alpo):
Who is primarily responsible for the feeding?
Quantity of food given:
At what approximate time(s) of day is food given?
Where is the dog fed (physical location)?
Where is the dog fed in relation to other dogs in the household?
If so, provide details:
What are your dog's favorite foods?
How much water does your dog drink in a day?
How many water bowls are provided?
If so, provide details:
Where does your dog sleep?
If it sleeps on your bed, who invites it up?
When does your dog get up in the morning?
If yes, how often and have you any idea why?
When does your dog get to go outside and how long does it like to stay out for?
How does your dog ask to go outside?
If Other, please describe:
If Other, provide details:
Provide details of the frequency of exercise:
If yes, provide details:
If other, provide details:
What does your dog do as you prepare to depart?
Typically, how long is your dog left alone without human company on any given day?
What does your dog do during family meals?
If yes, provide details:
List the five things your dog likes the most (e.g., specific activities, food, toys)
If other, provide details:
To which areas of your home does your dog have access?
Please describe your dog's reaction, aggression exhibited, and to whom during handling/grooming:
Please describe your dog's reaction, aggression exhibited, and to whom during petting or hugging:
Please describe your dog's reaction, aggression exhibited, and to whom when disturbed during resting:
Please describe your dog's reaction, aggression exhibited, and to whom during disciplining:
Please describe your dog's reaction, aggression exhibited, and to whom when walking on a lead:
Please describe your dog's reaction, aggression exhibited, and to whom when taking food away:
Please describe your dog's reaction, aggression exhibited, and to whom when taking other objects away:
How does your dog behave when visitors come to the house (e.g., barking, door charging)?
If yes, provide details:
If yes, provide details:
If yes, provide details:
If yes, how many times?
If yes, please provide the information (Name(s), purpose(s), time and days, dog's reaction(s))
What is your dog's response to frequent visitors?
What is your dog's response to occasional visitors?
What is your dog's response to rare visitors?
Details:
Details:
Details:
Details:
Details:
Details:
Details:
Details:
Details:
Details:
Details:
Details:
If yes, please specify whom or what is the target:
If yes, please specify which regions:
If yes, give details:
If yes, describe these:
Describe the problem you are currently experiencing with your dog:
How old was the dog when the problem began?
Where does the problem commonly occur?
How often does it occur?
Additional details about the problem:
If yes, please explain in detail:
Describe the most recent incident and the setting in which is occurred (be precise):
Where was the dog?
Where was everyone else in relation to the dog?
What was everyone doing prior to the incident?
What was the dog's body posture (position of ears, tail, face, hair on back)?
What was your reaction or response?
What was the dog's reaction to your response?
If so, give details:
Describe the previous three incidents prior to the most recent incident:
If other, please explain:
What has been done to correct the problem?
Do you suspect any cause?
How would you describe your own and your family's relationship with this dog? (Adult owners & children)
What are your own and your family's feelings about the dog's present behavior? (Adult owners & children)
What is your expectation for change?
Under what circumstances would you consider rehoming this dog?
Under what circumstances would you consider relinquishing this dog to a shelter or rescue?
Under what circumstances would you consider euthanasia?
Describe the scenarios seen in videos:
