Canine Behavior Survey

Please fill out this confidential form and submit at least 48-hours prior to your scheduled appointment. The information you provide is important for an accurate understanding of your dog’s behavior problem and development of an effective intervention plan. Detailed and honest responses are valuable. These forms save time during the consultation allowing us to concentrate on the plan.

Canine Behavior Survey

Client Information

Pet Information

Household

Please list all people in household and people that your pet comes into regular contact with (ex. Dog Walker). List name, age and relationship for each person.

Please list all other animals in household.

Other animals in household

plus1 Add Additional Animal minus1 Remove

Household2

Pet Ownership

Medical Information

Diet

Exercise

Training

Have you ever used any of the following for punishment or training?

The Problem

Rank the above problems from most distressing to least distressing:

Descriptive episodes

Please describe, in detail, the most recent incident representative of the problem behavior. Include what your dog was doing before and after the incident, as well as how you reacted: (date of episode:)

Please describe, in detail, the most serious episode of the problem behavior. Include what your dog was doing before and after the incident, as well as how you reacted: (date of episode: )

Please describe, in detail, the first episode of the problem behavior that you remember. Include what your dog was doing before and after the incident, as well as how you reacted:

Please indicate your dog’s reaction to the following situations by placing an “X” in the appropriate box

Behavior with human household members

Behavior with VISITORS and STRANGERS

Behavior with UNFAMILIAR DOGS

Aggressive Behavior

Goals

What SPECIFIC goals do you have for your pet as a result of this consultation?

How serious do you and other members of the household find the main problem:

Section

plus1 Add another family member minus1 Remove

Thank you for completing this questionnaire. Two hours have been reserved for your consult. I look forward to helping you with your concerns

Sending