Pre-Consultation Questionnaire

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* 1. Your Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Dog's Details:

Name:

Age

Breed

Sex

Desexed?

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* 3. How many people are in the home? Are there children? What are their ages?

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* 4. Vet Information

Regular Vet Clinic

Reason for most recent vet visit?

Any medical conditions?

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* 5. Compliant/ Problem 1: Rate Seriousness and provide information

Very Serious

Serious

Not Serious

Problem behaviour or complaint

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* 6. Compliant/ Problem 2: Rate Seriousness and provide information

Very Serious

Serious

Not Serious

Problem behaviour or complaint

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* 7. Compliant/ Problem 3: Rate Seriousness and provide information

Very Serious

Serious

Not Serious

Problem behaviour or complaint

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* 8. Please select any behaviours that your dog exhibits (Aggression and Fear related)

Resource Guarding

Handling aggitation

Reactive to Strangers

Aggression/intimidation of household members

Reactivity to other dogs when on lead

Reactivity to other dogs when off lead

Aggressive to Cats

Barking

Destruction

House Soiling

Impulse Control

Separation Anxiety

Movement Sensitivity / Prey Drive

Baby / Child Preparation, Assistance

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* 9. If a bite to Humans or Dogs

No Bite History

Dogs Only - Provide selection of bite details

People Only - Provide selection of bite details

Bared Teeth / Snarl / Growl

Snap (1)

Contact - No Damage (2)

1-4 shallow punctures (3)

1-4 deep punctures, bruising (4)

Deep bi-directional tears (5)

Multiple level 4 and 5 (6)

Mutilation or fatality

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* 10. How are you feeling while handling your dog in these scenarios?

Confident, I just want to know what I should do

I get nervous and feel the dog feeds on my reactions

I can no longer be involved in activities with my dog

I'm ok, but need help to build my confidence further

Other (please specify)