Detailed Behavior History - Aunt Penny's Professional Dog Training

Canine Questionnaire

To properly prepare for your pet’s challenges the specific information requested in this form is needed by the trainer. We do understand that you may have recently acquired this pet or not know the answer to a question – complete it to the best of your ability given the knowledge you have.

If there is a problem finishing the form as provided contact us ASAP at info@myauntpenny.com

"*" indicates required fields

Step 1 of 11 – Basic Information

Today's Date*

MM slash DD slash YYYY

Penny is a Nationally Certified Professional Dog Trainer CPDT-KA * Certified FEAR FREE Professional Licensed Family Paws Educator for the International Dogs & Storks ® and Dogs & Toddlers ™ programs.

Your Name*

First Last

The legal owner/owners of the dog are:*

List all owners full names

Address of owner*

Street Address City State ZIP Code

Cell Phone*

Home phone

Email*

We will send correspondence to this email.

Would you be available sessions on:*

Weekend sessions can take a month to get.

Is there a certain day of the week that works best for you?*

My daytime hours are 11-4 pm evening is 6-9. Weekends are 1-7 pm.

Would you consider your need for a trainer urgent (within 3 days)?*

Most sessions take 2 -4 weeks to schedule. There is no guarantee of availability but every effort will be made to respond quickly.

Are you expecting a baby? If yes, when?*

Are you adopting a baby? If yes, when?*

Do you have a baby or toddler currently in your home?*

Do you have children under the age of 10 in your home on a regular basis?*

Has your dog bit or threatened a child?*

Has your dog ever been deemed a dangerous dog by the courts or by animal control?*

Has your dog ever killed any animal? If so what animal?*

List all ( including you) family members and NON family members that live in your house:*

To add members, click the plus sign.

Name

Male/Female

Age

Is anyone in your home afraid of this dog?*

Please explain.

List all pets that live in your house:*

To add pets, click the plus sign.

Name

Species

Age

M/F

Get along with dog?

Date gotten

Upload a photo of your dog.

If your image is online, use the other field to add the link instead.

Accepted file types: png, jpg, Max. file size: 256 MB.

Add link to photo instead of upload

Files should be JPG, PNG or WEBP

Did you acquire your dog after 3 months of age?*

Did you acquire your dog at 6 weeks of age or less?*

Was your dog acquired from a shelter or a pound?*

Has your dog had multiple owners during his/her life?*

Was your dog acquired from a pet shop?*

Has your dog had multiple owners during his/her life?*

Was your puppy an orphan or hand raised?*

Was your dog the single puppy in a litter?*

Dog's Name*

Dog's breed*

Color

Age*

Sex*

Is your dog sprayed/neutered?*

Age of neutering?

Is your dog microchipped*

Is your dog CURRENT on their dog license?*

Has your dog EVER bitten another dog ( not including playbiting , or mouthing )*

Check all that apply.

My dog has growled but never bit

Yes but it left no mark

Yes the bite bruised the skin

Yes the bite left a puncture mark

Yes the bite tore the skin

Yes the bite left multiple puncture wounds

Yes my dog has bitten several dogs

Yes the dog killed a dog

Dog bite information

Please include details: Size of dog bit * Male or female or unknown* medical treatment needed? * Why do you think this happened? *Name of dog victim

Has your dog ever bit a person?*

Check all that apply.

I’m not sure if it was play or aggression

My dog has growled but never bit anyone

Yes but it left no mark

Yes the bite bruised the skin

Yes the bite left a puncture mark

Yes the bite tore the skin

Yes the bite left multiple puncture wounds

Yes the dog killed a person

Is there a current or upcoming lawsuit pertaining to this dog for ANY reason?*

Dog Bite DOG history

Use this comment area below if additional space is needed

Victim

Age

Male/Female

Part of body bit

Medical treatment needed?

Stitches?

Why do you think it happened?

Any additional comments about HUMAN dog bite history ?

Name of current veterinarian*

Name of vet clinic*

Vet Address*

Street Address City State ZIP Code

Vet Phone Number*

Consent*

I give permission for Penny Layne to contact my vet/vets or their staff – for any reason for health, safety, to collect more info, or to discuss my dog/ dogs before or after my consult/training.

We must have consent to accept a new client.

Is your dog able to be handled by the vet without a muzzle?*

Yes

Date of last physical*

Flea/Tick prevention name?*

If none – mark N/A

Heart worm prevention name?*

If none – mark N/A

Are all vaccines current?*

Yes

Any dog 12 weeks and older must have rabies as this is a state law

Does your dog have any medical issues?*

Yes

Please explain the medical issues.

Has your dog been seen for these medical issues?*

Yes

Pease list all current medications & supplements:

Please include the dose

Issues you would like to discuss with the trainer:*

Check all that apply

Dog and Baby interactions

House training

Demands attention

Submissive excitement urination

Fearful or Shy

Anxious

Aggressive to people

Aggressive to dogs

Separation anxiety

Resource guarding (Food, toys, objects, people, locations) with people

Resource guarding (Food, toys, objects, people, locations) with DOGS

Destructive tendencies

Jumping on people

Behavior with visitors

Excessive energy

Excessive barking

Fighting with another dog in our home

When guests enter my home my pet will:*

Check all that apply

Greet the guest calmly

Ignores guests

Jumps on them

Barks a few times

Barks non-stop

Whines

Hides

Pees

Charges/ lunges at them

Threatens them

Is in a crate

Is behind a gate

Is outside

Is in another room

I’m not sure yet

Other

Is your dog social with unfamiliar people?*

Check all that apply

Seems to love everyone

Good with unfamiliar woman

Good with unfamiliar men

Good with unfamiliar children

Good with unfamiliar infants

Okay in their presence but doesn’t want them to pet him

Not sure

How do you address undesirable behavior such as jumping, barking etc.?*

Check all that apply

Interrupt

Redirect

Place in crate

Verbal reprimand

Physical reprimand

Correction with choke collar

Correction with pinch or prong collar

Correction with shock collar

Other

What is your dog afraid off or what does your dog threaten*

Check as many of these that apply

None

Thunder /storms

Yelling

Children

Other dogs

Movement by people in the house

Cars/ trucks

Baby/toddler

Uniforms

Cat

Vacuum sweeper

Men

Woman

Hats

Vet

Groomer

Other

NAME of dog food*

Frequency of feeding*

Other food/treats/table scraps:

Does your dog eat:*

Do you have to be present to eat?*

What exercise does your dog get and how often?*

Does your dog go to the dog park*

Does your dog go to doggie daycare?*

Do you have a fenced-in yard or the Invisible Fence?*

What height is your fence? ( if not invisible)

What are your goals for training?*

What 3 things do you love the most about your dog?*

What 3 things don’t you like about your dog?*

What type of collar or harness has EVER been used on your dog?*

Have you attended any group training classes with your dog?*

Class name and approximate date

Have you previously enlisted the help of a trainer or behaviorist for this behavior problem?*

What is the name of the trainer and/or training facility you have used?

What is the website for the training facility you have used?

Is your dog crate trained?*

Has your dog been trained to wear a muzzle?*

Does your dog do the following willingly*

Sit

Fetch

Leave it

Loose leash walk

Heel

Watch me

Come

Down

Drop it

Stay

Go to your place

Do tricks

Is your dog protective of his toys or bed with dogs?*

Is your dog protective of food with humans?*

Is your dog protective of food with dogs?*

Does your dog ever seem irritated by or resent petting?*

Is your dog comfortable in crowds?*

How does your dog act when he meets or passes strangers away from the house?*

Is your dog frightened excessively by any noise?*

Please explain.

Is your dog frightened excessively by anything else in the environment?*

Please explain.

The following questions DO NOT mean we are recommending this.

Are you considering rehoming your dog?**

Are you considering euthanizing your dog?*

Is there anything else you would like to tell us about your dog and its behavior?

How did you hear about us?

What brought you to contact me today?

Please initial here acknowledging I have been honest with the trainer for both her safety and the success of my dogs’ consult/ training.*

Thank you for taking the time to complete this form. Your answers will allow us to serve you better. We look forward to meeting with you and your dog. If you have any questions, please do not hesitate to ask.

By electronically signing below, you agree to the foregoing terms of payment:

Signature*