Detailed Behavior HistoryDetailed Behavior History - Update 2015Step 1 of 714%Today's Date* Please answer the questions that follow as thoroughly as possible. We must receive this form at least three days before your appointment. All answers are confidential and will help us to serve you better.General InformationName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Dwelling*HouseTownhouseApartmentFenced Yard?*YesNoInvisible Fence?*YesNoEmail* This email will be used for all communication with the trainer.Phone*Work PhoneCell Phone*Occupation* Pet InformationDogs Name* Breed/Mix*D.O.B. or Age*Weight*Color/unique markings*Sex of Pet*MaleFemaleSpayed/Neutered?*YesNoIf spayed/neutered, at what age?If spayed/neutered due to a behavioral problem, explain.How Did You Hear About UsHow did you hear about us?*VeterinarianFormer clientInternetAdvertisementBreederRescue/ShelterPet-related businessOtherPlease select the best optionName of referring individual, organization or publication:Dog’s BackgroundWhere did you obtain your dog?*BreederIndividualShelterRescue groupPet storeFriend/relativeHow long have you had your dog?*Were there previous owners?* Yes NoWhy was the dog given up?Type of ID?*MicrochipRabies/license tagName tagTattooMore About Your DogWhy did you get your dog? Please check all that apply* Companionship For the kids For protection To breed Received as a gift Sports/work (e.g., competition obedience, agility, hunting) Assistant/service/therapy/emotional support Companion for othe dog OtherHave you owned other dogs in the past?*YesNoWhat breed?List any physical/breed characteristics that contributed to your choice for your current dog:MedicalVeterinarian’s name*Clinic's Name*Vet Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date last visit:*Reason*Date last vaccinated:*Vaccine(s) given*Current health problems/medications*Past medical conditions/treatment*Does your dog have any allergies, including food allergies?*YesNoIs your dog easily handled by the vet staff?*YesNoHas he/she ever had to be muzzled?*YesNoIs your dog on heartworm preventative?*YesNoHeart worm BrandIs your dog on flea and/ or tick preventative?*YesNoFlea/Tick Prevention BrandI give permission for my vet to be contacted by the trainer if the need arises for health, behavior or information pertaining to this dog.*YesPlease initial here acknowledging contact of your vet.Diet EliminationWhat brand of food do you feed?* Raw Dry kibble Canned OtherHow many times a day?At approximate time of day?Does your dog finish all food at meals?*YesNoIf not, how long is the food left down?Does your dog receive other treats/chewies?*YesNoFrequency/type:Please list 3 of your dog’s favorite foods/treats:* Has your dog ever become possessive of his food or a treat?*YesNoPlease describe in as much detail as possible:Is your dog reliably housetrained?*YesMostlyNoIs your dog crate trained?*YesNoPaper/pad trained?*YesNoLitter box trained?*YesNoDo you have a dog door?*YesNoHow many times daily do you let your dog out (or take him on walks) to eliminate when you are at home?How many times per day does your dog normally defecate?ExerciseWhat type of exercise does your dog get?*(If not receiving any exercise at this time, note “none” and the reason.)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.”)Who is normally responsible for exercising your dog?*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.”)Does your dog ever become reactive toward other dogs or people on walks?*YesNoPlease decribed the reactions.Environmental/LifestyleList all people, including yourself, who live in your household:*NameGenderAge (if child)Relationship to you Who will be responsible for practicing training exercises with the dog?*Does your dog “belong to” a particular household member (e.g., son) or everyone?*Do any household members dislike the dog, and if so, why?*Are any household members frightened of the dog, and if so, why?*Is the dog frightened of any household members, and if so, why?*Where is your dog kept when you are not at home?*Indoors not confinedIndoors confinedIn yard not confinedIn yard confined to dog runIn yard tied out or chainedWhen you are at home, is your dog allowed in the house?*YesNoIf your dog is not allowed indoors at all, why not?*AllergiesCleanlinessNot potty trainedWe prefer itDestructiveIf your dog is an outdoor dog, would you like him to eventually be able to be indoors?*YesNoN/AHow: crated, penned?If so, how long is your dog confined on an average day?Reason for confinement?If indoors, is your dog ever confined (crated, penned) while you are home?*YesNoWhere does your dog sleep at night?*In a crate?*YesNoHow many hours per day is your pet without human companionship?*Do you have other pets?*YesNoIf so, what kind, breed, age, sex, neutered?If your other pet is a dog or cat, how does your dog get along with the other pet?Three things I like and dislike about my dog:*LikeDislike Does your dog play with toys or play games?*YesNoIf so, what are his favorite toys/games?(These may be interactive games like tug or toys he plays with alone.)What other activities does your dog enjoy?*TrainingType of Training*No training yetTrained ourselvesPuppy groupBasic groupIntermediate groupAdvanced groupPrivate lessonsSent to trainerIf group class, did you complete the course?YesNoTraining methods tried (check all that apply):* Food treats Praise Verbal corrections Physical corrections Shock collar Citronella collar Board and train Vibration collar OtherPlease name any trainer or club that has trained you and your dog.*Behavior your dog knows*SitDownStayComeLeave itGiveWaitQuiet Indicate the percentage of time he/she will do so when asked.More behaviors your dog knows*Walk nicely on leashGo to your placeOff (furniture or when jumping)Others (including tricks) Indicate the percentage of time he/she will do so when asked.Check the behaviors that apply to your dog:* Aggressive Fearful Anxious when alone Jumps on people Pulls on leash Destructive when alone Mouthing/nipping Chews furniture/property Digs in yard Urinates in house Urinates when excited Defecates in house Steals food/objects/trash Darts out doors/gates Escapes from yard Guards food/toys/chewies/other Excessive attention-seeking Jumps on furniture Play biting Stool consumption Understands but will not obey Excessive vocalization when alone Excessive voc. when we’re home Threatening/biting family members Threatening/biting strangers Threatening/growling at other animals OtherPlease check all that applyIf your dog is agressive, fearful or other, please explain.What would you like help with, in order of importance?*Has your dog ever bitten anyone?*YesNoHas your dog ever bitten any animals?*YesNoPlease describe in as much detail as possible:Has medical attention been necessary (for humans or animals) because of any aggressive incident?*YesNoPlease explain:What is your dog’s usual reaction when a person he has not met before enters the home?*When was the last time a person unfamiliar to your dog entered the home?*Is there anything else you feel it would be important for us to know?* 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.