New Client Form Your Animal's Info Your Animal’s Species Your Animal's Name Sex Female, spayed Female, intact Male, neutered Male, intact Breed Age How long has s/he been a part of your household? Where did you get him or her from? Breeder Rescue Shelter/Humane Society Pet store Stray Other How much exercise does your animal get each day, and what form does this take? Please specify weekdays versus weekends. How does your animal spend his/her days? Is s/he crated, and if so, for how long? Does s/he have free run of the house? Is s/he kept outside? What food do you feed your animal ? What brand? Dry kibble, wet food or a combination of the two? Is this your first animal ? Yes No Please list the people who interact with or care for your animal . Are there any other animals in the house? Please list name, breed, sex and age. Problem Behavior Problem behavior(s), or reason you are seeking an in-home consultation. When did this behavior start? Less than a month ago Between a month and and six months ago More than six months ago Has anything else changed in your animal's life around the time you became aware of this behaviour? Did you move? Did anyone new join the household? Were there any changes in the animal's daily routines? How frequently does the animal engage in this behaviour? Have you tried to manage, alter or change this behaviour? If so, what methods have you used? Do you scold him or her? What have you tried? Is the behaviour getting better or worse? Please explain. Has your animal ever lunged and snapped at a person? Yes No Don't know Has your animal ever bitten a person? Yes No Don't know If yes to either of the two above questions, please give additional details. What happened just prior to the bite? How badly was the victim injured? Has your animal ever lunged and snapped at another animal or pet? Yes No Don't know Has your animal ever bitten another animal or pet? Yes No Don't know If yes to either of the two above questions, please give additional details. What happened just prior to the bite? How badly was the victim injured? If your animal has bitten or threatened to bite, please rate the most severe incident: Level 1 Obnoxious or aggressive behavior but no skin-contact by teeth (lunges but no contact made) Level 2 Skin-contact by teeth but no skin-puncture. There may be skin nicks (less than one tenth of an inch deep) and slight bleeding caused by scraping of teeth against skin, but no vertical punctures Level 3 One to four shallow punctures from a single bite (animal bit and quickly released) Level 4 One to four punctures the full depth of the teeth with bruising around the punctures (animal bit and shook his/her head before releasing) Level 5 Multiple-bite incident with rending and tearing Level 6 Bite killed victim None of the above Training Type of training you and your companion animal have participated in (check all that apply) In-home private consultations Group classes Puppy classes Puppy play group Agility, Rally or other sport Have you ever used aversive or correction based training with this animal? Yes No Not sure Are you willing to use positive, reward-based methods to correct this behaviour? Yes No Not sure Medical Please tell us about any medical conditions you are aware of. Does your animal have any allergies? Food or environmental? Does your animal take any medications, pills, supplements or prescriptions? If so, what is s/he taking and how often? Name of your veterinarian * Vet’s address or location Vet’s phone number * (###) ### #### Last visit to the vet (approximately) Contact Information Your Name * First Name Last Name Your Email * Phone Number * (###) ### #### Address: Address 1 Address 2 City State/Province Zip/Postal Code Country How should we contact you? Email Phone Best time to contact you: How did you find out about us? Thank you! We’ll contact you shortly.
