Part 1 - CLIENT INFORMATION

Please answer the questions that follow as thoroughly as possible. All answers are confidential and will help us to serve you better. 

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* 1. Today’s Date

Date

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* 2. Please answer the questions that follow as thoroughly as possible. This form should be received with your payment at least a week before the training appointment. All answers are confidential and will help us to serve you better.

Owner's Name

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* 3. Email address

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* 4. Address

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* 5. Phone numbers

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* 6. Dog's Information

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* 7. What is your dog's weight?

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* 8. Was your dog spayed/neutered due to a behavior problem?

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* 9. Home setting:

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* 10. Where did you obtain your dog?

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* 11. How long have you had your dog?

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* 12. Were there previous owners?
If yes, why was the dog given up?

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* 13. Type of ID

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* 14. Why did you get your dog? Please check all that apply.

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* 15. List any physical/breed characteristics that contributed to your choice for your current dog:

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* 16. MEDICAL: 
Veterinarian's name:

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* 17. What city is the clinic located in? 

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* 18. Month/Year of last visit:

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* 19. Reason for visit:

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* 20. Date last vaccinated:

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* 21. Vaccine(s) given: 

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* 22. Current health problems/medications:

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* 23. Past medical conditions/treatments: 

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* 24. Does your dog have any allergies, including food allergies?

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* 25. Is your dog easily handled by the vet staff? 

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* 26. Has he/she ever had to be muzzled while at a veterinarians clinic?

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* 27. Is your dog on heartworm preventative? 

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* 28. If yes, what brand?

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* 29. Is your dog on flea and/or tick preventative? 

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* 30. If yes, what brand?

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* 31. May we contact and discuss health and behavioral issues with your veterinarian? (if yes, please type initials. Type "no" to decline.)

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* 32. DIET AND ELIMINATION:
What type of food do you feed? (e.g., raw, dry kibble, canned)

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* 33. Regarding your dog's food:

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* 34. Has your dog ever become possessive of his food or a treat? If yes, Please describe in as much detail as possible:

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* 35. Is your dog reliably housetrained? 

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* 36. Is your dog crate trained? 

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* 37. Is your dog Paper/pad trained? 

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* 38. Is your dog Litter box trained? 

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* 39. Do you have a dog door? 

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* 40. If not, how many times daily do you let your dog out (or take him on walks) to eliminate when you are at home?

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* 41. How many times per day does your dog normally defecate?

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* 42. EXERCISE:
What type of exercise does your dog get? (If not receiving any exercise at this time, note "none" and the reason.)

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* 43. How long does the exercise last/how often is it provided? (For example, "a 15 minute walk three times daily", or "plays with neighbor's dog for an hour once a week.")

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* 44. Who is normally responsible for exercising your dog? 

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* 45. If walks are provided, what type of collar and leash is being used?
Collar examples: "regular buckle collar". "head halter", "body harness", "pinch/prong collar", "choke chain".
Leash examples: "6-foot nylon leash", "retractable leash".

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* 46. Does your dog every become reactive toward other dogs or people on walks? Answer "No" if they do not. If they do, type "yes" and describe the reactivity.

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* 47. ENVIRONMENT/LIFESTYLE:
List all people, including yourself, who live in your household. Include name, gender, age (if children), and relationship to you. 

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* 48. Who will be responsible for practicing training exercises with the dog? 

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* 49. Does your dog "belong to"  a particular household member or (e.g. son) or everyone? 

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* 50. Do any household members dislike the dog, and if so, why? 

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* 51. Are any household members frightened of the dog, and if so, why? 

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* 52. Is the dog frightened of any household members, and if so, why? 

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* 53. Where is your dog kept when you are not at home? 

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* 54. When you are at home, is your dog allowed in the house?

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* 55. If your dog is not allowed indoors at all, why not? O Allergies O Cleanliness O Not potty trained O We prefer it

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* 56. If your dog is an outdoor dog, would you like him to eventually be able to be indoors?

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* 57. If indoors, is your dog ever confined (crate, penned) while you are home? 

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* 58. If so, how long is your dog confined on an average day?

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* 59. What is the reason for the confinement described above (type N/A if it doesn't apply)

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* 60. Where does your dog sleep at night? (If in a crate, please describe)

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* 61. How many hours per day is your pet without human companionship? 

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* 62. Do you have other pets?

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* 63. If so, what kind, breed, age, sex, neutered?

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* 64. If your other pet is a dog or cat, how does your dog get along with the other pet?

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* 65. Does your dog play with toys or play games? If so, what are their favorite toys/games? (These may be interactive games like tug or toys they play with alone.) 

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* 66. What other activities does your dog enjoy? 

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* 67. TRAINING:
Select the options that include the training your dog has received:

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* 68. List organization name and/or trainer’s name:

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* 69. Training methods used (check all that apply): O Food treats O Praise O Verbal corrections O Physical corrections

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* 70. Next to each behavior your dog knows, estimate what percentage of the time they will do so when asked. If your dog doesn't know a behavior, type N/A.

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* 71. Does your dog know any other behaviors or tricks that are unlisted?

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* 72. Check the behaviors that apply to your dog and describe in the text box that follows: 

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* 73. Please describe any behaviors selected: 

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* 74. List any procedures/training equipment you've used to try to correct the behaviors checked on the previous page:

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* 75. What would you like help with, in order of importance:

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* 76. Has your dog ever bitten anyone?

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* 77. Has your dog ever bitten any animal?

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* 78. If you answered "yes" to either of the two questions above, please describe in as much detail as possible:

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* 79. Has medical attention been necessary (for humans or animals) because of any aggressive incident?

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* 80. If yes, please explain: 

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* 81. What is your dog's usual reaction when a person they have not met before enters the home? 

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* 82. When was the last time a person unfamiliar to your dog entered the home? 

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* 83. Is there anything else you feel it would be important for us to know?

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