Evaluation Questionaire Question Title * 1. Owner's Information Name Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 2. How did you hear about us? Facebook Website Instagram Referral/Other Please Explain Question Title * 3. What is the best way to contact you? Phone Email Question Title * 4. Dog's name? Question Title * 5. Gender of your dog? Male Female Question Title * 6. Breed Question Title * 7. Dog's age and Weight Question Title * 8. How old was the dog when you acquired it? Question Title * 9. Has your dog been? Spayed Neutered None of the above Question Title * 10. Where did you acquire your dog? Breeder Pet Shop Rescue Other Question Title * 11. Is this your first dog? Yes No Question Title * 12. Have you ever trained a dog? Yes No Question Title * 13. Briefly state what you would hope to accomplish during training? Question Title * 14. Is your dog house trained? Yes No Question Title * 15. Is your dog crate trained? Yes No What type of crate are you currently using Question Title * 16. How does your dog do in the crate? Question Title * 17. Describe any previous obedience training. Question Title * 18. Level of Success? Poor Fair Moderate Excellent Question Title * 19. What commands currently work best? Question Title * 20. What member of the family has the best control of your dog? Question Title * 21. Does your dog know how to walk on a leash? Yes No Question Title * 22. Is your dog good with other dogs? Yes No Question Title * 23. Does your dog react negatively to any of the following? (check all that apply) Giving pills Bathing Patting head Grasping collar Being lifted Meeting strangers Being vetted Being left alone When approached while eating When approached with a treat or toy To strangers outside the home To people entering the house/yard To children or Infants While in the car to people outside of the car To other dogs inside the home To other dogs outside the home When the dog is removed from the bed or furniture Question Title * 24. Check the behavior problems that you are having with your dog. (check all that apply) Jumping up Chewing Digging Barking Whining Pulling on leash Will not come when called Will not go into a crate Counter surfing Getting on furniture Will not behave in public places Rush the door when someone enters Aggressive toward family members Question Title * 25. Does your dog exhibit any of the following behaviors? (check all that apply) Cowering Ears back Tail Tucked Retreating Hiding Excessive Salivating Pacing Growling Showing teeth Question Title * 26. Describe any of the above in more detail if needed Question Title * 27. Is anyone in your family afraid of your dog? If so please describe Question Title * 28. Do you ever muzzle your dog for safety? Yes No Question Title * 29. Has your dog ever bitten a person? Yes No Question Title * 30. Has your dog ever been reported to animal control for biting? Yes No Question Title * 31. Has your dog every attacked another animal? If yes, please explain Question Title * 32. Please give any additional information regarding fear or anxiety in your dog Question Title * 33. Describe any situations where your dog appears fearful and/or aggressive. For example thunder, fireworks, loud noises etc. Question Title * 34. Veterinarian Information Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Phone Number Question Title * 35. Is your dog current on all vaccinations including rabies? Note: Any dog signed up for training must be up-to-date with vaccines. Yes No Question Title * 36. Would you provide proof of vaccinations from your vet? Yes No Question Title * 37. Please give the date of your dog's last heartworm preventative Date / Time Date Question Title * 38. What was the date of your dogs last flea and tick treatment? Date / Time Date Question Title * 39. Please list ALL medications your dog is currently taking Question Title * 40. Please list any medical problems your dog currently has or had in the past Question Title * 41. Please list any other information you feel we need to know Done
