Dog Background Form:

Note: The Canine Behavior Counselor will conduct the private consultation in the client's home (within a 15 mile radius from Mechanicsburg, PA 17050).  A client living outside the 15 miles radius may be requested to travel to the Canine Behavior Counselor or be willing to pay a "distance and time" compensation charge for the extra distance traveled outside the defined service area.

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
FAX
E-mail

Dog Information:

Name
Age
Sex Male Female
Breed
Weight

Age of dog when you acquired it?

How did you acquire your dog?

Did the dog have multiple owners before you?

Is your dog neutered/spayed?

Age your dog was neutered/spayed:

Why did you decided to neutered/spay your dog? (if applicable)

Did you notice any behavior changes after your dog was neutered/spayed? If yes, please explain.

Enter the date of dog's last physical exam at Veterinary Office:

-- mm/dd/yy

Does you dog have any medical problems? If yes, please explain:

List any medications your dog is on:

What type of dog food do you feed your dog?

How many times a day do you feed your dog?

Describe your dog's behavior problem(s) in detail:

Age your dog first exhibited this behavior problem?

Did you seek any other professional to help resolve your dog's behavior issue?

Yes No

What is the duration of each behavior problem incident?

What is the frequency of occurrence for the behavior problem (daily, weekly, ect..)?

Has there been changes in the pattern, frequency, intensity or length of incidents from the time of onset to present?

Are there any specific conditions which seem to trigger the behavior?

Can the dog be interrupted when engaged in the behavior?

Yes No

How long is the interval between the behavior stopping and the beginning of the next occurrence?

Describe below any methods used to stop the behavior and what the dog's response to these methods are?


Where the methods above recommend by a professional trainer?

Yes No

Provide a detail description of the last time the behavior problem(s) occurred:

My dog's parents, siblings...engaged in similar behaviors or abnormal behaviors:

Parent - Mother
Parent - Father
Both Parents
Sibling
Dog's parents and siblings are fine...
I do not know this information...

List the age and sex of the people living in the dog's house (be sure to include children's ages and sex):

List other animals in the household (species, breed, age, sex, if neutered or not). In addition, was the animal acquired before or after the dog acquired?

Describe the interactions with the other animals in the household and the dog:

Describe the interactions between the dog and the family members:

Describe how your dog reacts to strangers:

How does your dog react to the veterinary office and during examinations?

Where does the dog live primarily (inside/outside)? Describe any restrictions to the dog's movements inside the house and or the kennel?

Describe a typical 24hr period in your dog's life, start with where and when the dog wakes up in the morning:

What amount of time is spent actively playing with the dog? What type of activities do family members do with the dog (fetch, walking, jogging)?


How much time is spent playing with other animals in the home?

Level of obedience classes the dog has attended:

Basic Obedience Level 1
Basic Obedience Level 2
Level 3+
Canine Good Citizen Certified
Dog has not attended basic obedience

Select what your dog will do willing for you:

Sit
Stay
Down
Heel
Come
Stand for grooming
Fetch
Do Tricks
Doesn't do anything willingly for me

List situations when your dog is less likely to obey you:

My dog will work well for (check all applicable):

Food
Praise
Ball
Frisbee
Retrieve Game
Petting
No reward

Check the statements that apply to your dog:

Dog demands to be petted
Seems irritated by or resents petting
Barks excessively
Cowers or runs away if people talk loud
Cowers or runs away if people act boisterously
Rolls over on back when greeting strangers
Urinates when greeting strangers
Rolls over on back when greeting you
Uncomfortable in crowds
Dog defecates in the house
Dog urinates in the house

How does your dog act when strangers come into the house?

How does your dog act when he meets strangers away from his home?

How does your dog act when he meets a strange dogs on leash?

How does your dog act when he meets strange dogs off leash?

How does he act if he and the other dog are both off leash?

My dog is frightened excessively by:

Thunderstorms
Flies
Bees
Gunshots
Any loud sound
Loud voices

List anything else your dog is extremely frightened of that we did not list in the previous question:

My dog likes to chase:

Running children
Joggers
Bicyclist
Cats
Any furry little animal
Cars

Select the most aggressive response your dog has exhibited regarding statement below:

Touch dog's food or add food while eating:

Walk past the dog while eating:

Take away real bone, rawhide or delicious food:

Walk by the dog when he has a real bone or raw hide:

Touch delicious food when dog is eating it:

Take away stolen object:

Physically wake dog up or disturb resting dog:

Restrain the dog when it wants to go some place:

Lift the dog:

Pet the dog:

Medicate the dog:

Handle dog's mouth or face:

Handle the dog's feet:

Trim the dog's toenails:

Groom the dog:

Bath or towel off the dog:

Pull the dog back by the collar or scruff:

Hold dog by muzzle:

Stare at the dog:

Reprimand the dog in a loud voice:

Visually threaten the dog with hand or a newspaper:

Hit the dog:

Walk by dog in crate:

Walk by or talk to dog on furniture:

Make dog respond to a command:

Do you consider your dog hyperactive?

Yes No

Does your dog ever get a glazed look in his eyes?

Yes No

Does your dog have a Jekyll and Hyde personality?

Yes No

Did your dog have a seizure within the last six months?

Yes No

Was your puppy an orphan or hand raised?

Was your dog the single puppy in a litter?

Does your dog follow you all around the house?

Does your dog become anxious at the sound of car keys?

Does your dog become aggressive when you leave?

Does your dog exhibit other problem behaviors as you prepare to leave?

Does your dog bark or whine excessively within 30 minutes of your departure?

After you depart does your dog's activity decrease?

After you leave does your dog seem depressed?

After you leave does your dog have loss of appetite?

Only in your absence does your dog destroy property?

Only in your absence your dog urinates or defecates in the home?

Does your dog regularly have diarrhea, vomit or lick excessively in your absence?

Does your dog exhibit excessive greeting on your return (jumping, hyperactivity, barking) more than three minutes?

What do you hope to accomplish and or achieve by contacting me regarding your dog's behavior problem?

What are the best days of the week to try and schedule a private consultation with your pack?

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
***Note: Weekend days are available, but get booked up fast.  If you can do a particular week day too, please be sure to check it off on the list above. Thanks!!!

What is the best time of the day to try and schedule a private consultation with your pack?

      Weekdays:

Early Morning
Mid Morning
Late Morning
Early Afternoon
Mid Afternoon
Late Afternoon
Early Evening

Weekends:

Early Morning
Mid Morning
Late Morning
Early Afternoon
Mid Afternoon
Late Afternoon
Early Evening

How did you hear about my services?

Business Card
Cast Away Critters
Furry Friends Network
Customer Referral
Humane Society
Pamphlet listing your services and contact info
PAWS
Veterinary Office Referral
Search Engine/Website Visit

Canine Behavior Center
Copyright © 2003. All rights reserved.
Revised: 09/29/08