Your Dog’s Name
Sex Female, spayedFemale, intactMale, neuteredMale, intact
Breed
Age
How long has s/he been a part of your household?
Where did you get him or her from? BreederRescueShelter/Humane SocietyPet storeStrayOther
How much exercise does your dog get each day, and what form does this take? Please specify weekdays versus weekends.
How does your dog 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 dog? What brand? Dry kibble, wet food or a combination of the two?
Is this your first dog? YesNo
Please list the people who interact with or care for your dog.
Are there any other animals in the house? Please list name, breed, sex and age.
Problem behavior(s), or reason you are seeking an in-home consultation
When did this behavior start? Less than a month agoBetween a month and and six months agoMore than six months ago
Has anything else changed in your dog'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 dog's daily routines?
How frequently does the dog 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 dog ever lunged and snapped at a person? YesNoDon't know
Has your dog ever bitten a person? YesNoDon'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 dog ever lunged and snapped at another dog or pet? YesNoDon't know
Has your dog ever bitten another dog or pet? YesNoDon't know
If your dog 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 puncturesLevel 3 One to four shallow punctures from a single bite (dog bit and quickly released)Level 4 One to four punctures the full depth of the teeth with bruising around the punctures (dog bit and shook his/her head before releasing)Level 5 Multiple-bite incident with rending and tearingLevel 6 Bite killed victimNone of the above
Type of training you and your companion animal have participated in (check all that apply) In-home private consultationsGroup classesPuppy classesPuppy play groupAgility, Rally or other sport
Have you ever used aversive or correction based training with this animal? YesNoNot sure
Are you willing to use positive, reward-based methods to correct this behaviour? YesNoNot sure
Please tell us about any medical conditions you are aware of.
Does your dog have any allergies? Food or environmental?
Does your dog 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)
Your Name: *
Your Email: *
Phone Number: *
Address:
How should we contact you? EmailPhone
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