New Dog (Canine) Questionnaire

The Pet Agency

5633 Kenneth Avenue

Carmichael, CA 95608

Telephone/Text: 916-968-3111

E-mail: michelle@thepetagency.com


Dog Owner Information:

Name:

Address:

Phone (home) (work) (cell)

Email:


Veterinarian Information:

Clinic Name:

Doctor's Name: Phone:

Who referred you to the Behavior Service?


Dog Information:

Name: Breed:

Date of Birth/Age Weight Color

Sex: Male Female Neutered/Spayed: Yes____ No____


Rabies Vaccination Status:

Date of last Rabies vaccination: ______________________ 1 Year 3 Year


Household Information:

People living in household:

Name

Age

Relationship (e.g. spouse, son, daughter, roommate, etc.)



















Other people in regular contact with pet (e.g. pet sitters, housekeepers, relatives, friends, etc.):

Name

Age

Relationship (e.g. pet sitters, friend, grandchild, etc.)




















Type of house: Single Family Detached Apartment Attached/townhouse

Mobile home Other


Neighborhood: Urban____ Suburban____ Rural_____

Do you have a yard? Yes No If yes, how big is the yard?

Is the yard fenced? Yes No If Yes, height of fence (ft)

Type of fence: Wooden slats Solid Wrought iron Chain Link

Other






Other pets in household (in order came into household):

Name

Species (e.g. dog, cat) &Breed (e.g., Golden Retriever, Manx)

Male/Female

Spayed/Neutered

Age Now

Age when obtained






































Acquisition Information:

How old was this dog when acquired? _______________________________________________

Where did you obtain this dog? Performance breeder (show, hunting, agility, etc.) ___________

Hobby breeder Private home/previous owner
Shelter/rescue organization Pet store Other


Behavior of dog's parents/litter mates (if known):


Describe previous home(s) (if known):


Why did you acquire this dog? (check all that apply):

Adult's pet Family pet Children's pet Companion to other pet

Protection Performance (show, hunting, agility, etc.) Breeding

Other ___________________________________________________________________



Neutering Information:

Is this dog Neutered/Spayed: Yes No_____

If YES: At what age?


If not neutered, reasons for not neutering (check all that apply):

Show dog Plan to breed Health concerns

Other







Medical History:

List any major illnesses/surgeries (dates):





List ALL medications/treatments your dog is currently receiving, including heartworm, flea preventative, dietary supplements, herbal/homeopathic treatments:

Name of medication

Dosage/frequency given

Date started medication






























Daily Activities and Routine:

Feeding:

When and where is the dog fed?

Who feeds?

Types of food: Dry (BRAND) % of diet

Canned (BRAND) %of diet

Raw % of diet

People food % of diet

Treats % of diet

Eating habits (check all that apply):

Eats right away Picky eater Anxious eater Guards food from people

Guards food from dogs Other


Sleeping:

Where does your dog sleep at night?


If disturbed while sleeping what is your dog's reaction (check all that apply)?

Happy Startled Growls Barks Bites Scared Grumpy Playful

Other


Exercise:

Leash walks: Does your dog get regular leash walks? Yes No


If NO, why? Doesn’t walk well (pulls) on leash Aggressive on walks

Don't have the time Medical reasons Other

If YES, who takes the dog for leash walks?

How often How long are the walks

Location (e.g. around neighborhood, in town, in park)


What do you use to walk the dog (check all that apply): Flat buckle collar Body Harness

Head collar (Halti, Gentle Leader) Training/choke collar Prong collar

Retractable leash Long leash (6ft + ) Average leash (4-6ft)

Short leash (4ft or less) Other


How is your dog on leash: Excellent (never pulls, pays attention to me) Good (rarely pulls)___ Fair (pulls but I'm able to control) Poor (pulls a lot, difficult to control)

Bad (pulls, I don't enjoy the walks)



Off-leash Exercise: Does your dog get off-leash exercise? Yes No

If Yes, who takes the dog for off-leash exercise?

How often For how long

Locations (e.g. trails, dog parks, beaches)


Living Spaces/Being Left Alone:

Where does your dog spend the most time when people are home:

Loose in house __ (with access to outside _ ) Confined (e.g. with gates) to part of the house (with access to outside __) Inside in a crate or pen___ Loose in the yard Outside in a kennel or pen Other


Where does your dog spend the most time when people are not home?

Loose in house __ (with access to outside _ ) Confined (e.g. with gates) to part of the house (with access to outside __) Inside in a crate or pen___ Loose in the yard Outside in a kennel or pen Other


How long is your dog left alone on an average day?

When is your dog left alone (e.g. 8:00am-5:00pm)?


What is your dog's reaction to being left alone (check all that apply):

Calm Depressed Barks Cries/howls Urinates/defecates Escapes Destructive Anxious Excited Aggressive








Describe a typical 24 hour day in your dog's life, starting with when and where the dog wakes up in the morning. Include feeding, exercise and play times. If behavior problems occur at particular times of the day include that information.














Training:

Has your dog had any training? No Trained Ourselves Classes/Met with Trainer­­­___

List type of classes, at what ages, and names of trainers:

Puppy classes

Group classes

Private lessons

Board & train

Other



What training techniques or tools have you used (all that apply): Training collar (choke) ______

Food rewards Verbal Praise Play/toys Prong collar

Remote collar (citronella, shock, vibration) Bark collars (shock, vibration, citronella)

Other

Who in the household trained the dog?

What commands does your dog know?


Did your dog enjoy training?


How well does your dog obey commands without distractions:

Very well Well Fairly Well Poorly Does not follow commands

How well does your dog obey commands with distractions:

Very well Well Fairly Well Poorly Does not follow commands


Behavior Screens:

Does your dog engage in the following behaviors at least weekly?:


No

When owner present

(times/week)

When owner gone

(times/week)

Don’t know

Housesoiling


(__________)

(__________)


Excessive barking/whining


(__________)

(__________)


Destructive chewing


(__________)

(__________)


Digging


(__________)

(__________)


Self licking/chewing


(__________)

(__________)


Pacing/repetitive behavior


(__________)

(__________)


Consuming non-food objects


(__________)

(__________)


Circling/chasing tail/freezing


(__________)

(__________)




How does dog react to the following?

Happy

Neutral

Fear/ Anxiety/

Submits

Snarl

Bark/

Growl

Snap/

Bite

Don’t

Know/

Don't Do

Unfamiliar people at door








Unfamiliar people in home








Unfamiliar people, neutral territory, on leash








--same, off leash








--same, approaching/trying to pet








Children on bicycles, roller blades








Joggers (adult)








Cars/trucks going by, on leash








Babies








Children








Unfamiliar dogs, on leash








Unfamiliar dogs, off leash








Squirrels/cats/small animals approaching dog








Person passing when dog in yard








Dog passing when dog is yard









How does your dog react to the following?

Happy

Neutral

Fear/ Anxiety/

Submits

Snarl

Bark/

Growl

Snap/

Bite

Don’t

Know/

Don't Do

Veterinary visits








Owners leaving








Owners returning








Car rides








Stranger approaching car








Thunder








Loud noises








Roughhousing








How does dog react when a family member does the following?

Happy

Neutral

Fear/ Anxiety/

Submits

Snarl

Bark/

Growl

Snap/

Bite

Don’t

Know/ Don't Do

Walk by food while dog eats regular dog food








Take food dish while dog eats








Walk by food while dog eats delicious food








Take away non-edible toy








Take away bone, rawhide








Take away stolen non-food item (e.g. socks)








Take away stolen food item (including dirty tissues, paper towels)








Reach for dropped food at same time as dog








Reach over head/pet on top of head








Pet on other parts of body








Brush








Bathe








Pick dog up








Put on/take off collar








Put on/take off leash








Disturb while sleeping








Move while on furniture








Approach the dog when it's sitting with a favorite person








Hold back when excited (e.g. from running out door) NOT WHEN AGGRESSIVE








Hold back when aggressive (e.g. barking at another dog)










How does dog react to a family member doing the following?

Happy

Neutral

Fear/ Anxiety/

Submits

Snarl

Bark/

Growl

Snap/

Bite

Don’t

Know/ Don't Do

Verbal reprimand








Leash correction








Physical reprimand








Staring at dog








How does dog react to a dog in the household?

Happy

Neutral

Fear/ Anxiety/

Submits

Snarl

Bark/

Growl

Snap/

Bite

Don't

Know/

Don't Do

Around regular food








Around rawhides








Around treats








Around toys








Around favorite people








While on walks together








During play










Has your dog ever bitten a person? No Yes


If yes, describe the victim(s): age, gender, and actions (e.g. 10 year old boy waving stick). Continue on additional pages if needed









How bad was the worst bite your dog gave to a person (check all that apply):

Made contact but didn't leave a mark Small red mark Bruised, didn't break skin Broke skin, minor scrape Broke skin, punctures Multiple punctures

Punctures and tore flesh Multiple bites at one time Required emergency treatment (describe)


Have any bites been reported to Animal Control or other authorities? No Yes

Comments:



Have any victims threatened/taken legal action because of an aggressive incident? N Y

If yes, describe incident:


Primary Behavior Problem:

What is the main behavior problem you wish to address at this appointment?




Describe the very first incident of this problem. Try to remember the earliest occurrence of the problem, even if it wasn't as serious as it is now. For instance, if your dog is aggressive to people, describe the first time she growled or barked at someone. Or if your dog has problems being left home alone, describe the first time he whined and cried when you left.


Include where the incident occurred, who else (human and animal) was present, what happened just before the incident, how everyone reacted.

Date of event Dog’s age (Approximate date/age is o.k.)








Describe per instructions above the most recent incident

Date of event Dog's age







Describe per instructions above at least one other incident you feel illustrates the problem behavior (if you would like to describe other incidents please do so on a separate page)

Date of event Dog's age







If you noticed any changes in your dog's body language or facial expression before, during or after the incidents please describe.




What would you like to see as an outcome for your upcoming appointment?




Frequency:

How frequently does this problem occur?

>10 times/day_____ 1-10 times/day_____ 1-6 times/week_____ <1x/week_____ <1time/month___


Is the frequency… Increasing_____ Decreasing_____ Unchanged_____


What percent of time that your dog is in a potentially problematic situation does the problem behavior occur?:

<25% 25-50% 51-75% 76-100%


Describe what you've tried to correct the problem and what the dog's response has been to each attempt.






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

Name Mild Moderate Severe Intolerable

Name Mild Moderate Severe Intolerable

Name Mild Moderate Severe Intolerable



Has anyone suggested you rehome this dog? Y N ___

Has anyone suggested you euthanize this dog? Y N ___

Have you or a household member considered rehoming this dog? Y N ___

Have you a household member considered euthanizing this dog? Y N ___


List other problem behaviors in order of importance to you. Due to the intense focus on your dog’s main problem, there may be limited opportunity to address these at the initial appointment.



LIABILITY:


Pet (Dog) Owner’s Name(print name):


Pet’s Name:



I (pet owner), (enter name--→)

have read the policies and procedures put forth above and understand them fully. I agree to adhere to these policies as a client of The Pet Agency.



Pet Owner Signature:


Date:



Pg. 12/12