Detailed Behavior History - Update 2018 Step 1 of 7 14% Today's Date* Date Format: MM slash DD slash YYYY Name* First Last Dog Name*All information provided is strictly confidential. Please complete this form by typing in the blanks provided and return it no later than two days before your PET’S appointment. 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 The person filling out this dogs’ information MUST be a legal owner of the dog. Please check the box indicating* I give consent that a deposit of $50 is non-refundable if you cancel with less than 48 hours of notice from your appt time. Your deposit does go towards your fee for the consult/training. Please confirm you agree to the following:* I agree to pay balance (via PayPal) 24 hours before consult. I agree to pay balance pay by CASH ONLY - NO CHECKS on day of appointment. The legal owner/owners of the dog are:*List all owners full names Is ANYONE in the home afraid of this dog ? If so WHY?*Who is filling out this informationOwners Name* First Last Physical Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneMobile Phone*Email* What appointment slots work best for you and your family?* Weekdays -DAYTIME Mon thru Fri 11 am-4 pm ( These are the quickest to get) Weekday -EVENINGS- Mon thru Fri 6 pm-8 pm Saturdays- 1 pm-7 pm ( waiting time can be a month) Please note any scheduling comments here:About YouYour Occupation*Do you live in a...*HouseMobile Home/TrailerApartmentTownhouse/CondoHas your household changed since acquiring your pet?*Please select all that apply Death of a pet Death of a family member Illness Divorce Marriage New baby College-bound child Schedule change Pet added Other No changes List all family members and NON family members that live in your house:*To add additional members click on the + signNameMale/FemaleAge Are there any environmental sounds near your home such as:*Please select all that apply Playgrounds Bus stops Trains Planes Motorcycles Other None/NA Your Dog InformationDog's Name*Dog's Photo* Drop files here or Accepted file types: jpg, jpeg, png. Dog's Breed/Mix*What are the color and markingsYou'll be asked to submit a photo before your appointmentSex* Male Femaie Is your dog spayed/neutered?* Yes No When was this done?Age*Weight*Is your dog microchipped?* Yes No Is your dog CURRENT on their dog license?* Yes No Lifetime Dog’s BackgroundWhere did you get your dog?*If rescue or shelter, please note which one.How old was your dog when you obtained him/her?*How long have you had your dog?*Reason for obtaining this pet:* Pet Hunting dog Watchdog Police dog Companion Other What is the NAME of your dogs food?*Is your dog food:*DryWetBoth are givenI feed raw onlyHow much does he/she eat a day and is it free choice or at a certain time (how many times a day )?*How long has your dog been on this current food?*Does you dog eat:*QuicklySlowlyDo you have to be present to eat?*YesNoWhat TREATS does your dog get?Do you feel that your pet drinks an excessive amount of water?*YesNoIs your dog protective around the food?*stiffens, growls, snaps, snarls or bitesYesNoWhere does your pet sleep?*Is your dog crate trained?*YesNoThree things you like about your dog:* Three things you don't like about your dog:* List all pets that live in your house:Species: Cat, dog, bird, etc.NameSpeciesAgeMale/FemaleGet along with dogWhen did you get? Your Dog's Vet InformationYou will be asked to provide a certificate of rabies before your apptWhen was your dog's last vet visit? Who was the vet?*Veterinarian’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 Vet Phone Number*Consent to Contact*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.Please initial here acknowledging contact of your vet.Is your dog able to be handled by the vet without a muzzle?*YesNoDoes your dog have any CURRENT medical issues?*YesNoHas your dog been seen by a vet for all of those medical issues?*YesNoAppointment ScheduledNot ApplicableDoes your dog have any allergies?*YesNoWhat is your dog allergic to?What Flea /Tick prevention is your pet using?*What heartworm prevention is your pet using?*Is your pet current on its vaccinations?*YesNoYou will need to show proof of rabies BEFORE the appointment.Has your dog been on medication for behavior at any time?*YesNoPlease list drug and dosage:Is your pet on any medications or suppliments currently?*YesNoPlease list the medication and suppliments: More About Your DogHow do you contain your dog?*Check all that apply. Select All Crates Tethers Cable run Outdoor pen Privacy fence Chain link fence Invisible fence Leash Other Where is your dog kept when you are not home?* Crate Gated in one room Roams the house Tied outside In fenced yard 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 pinch or prong collar Correction with shock collar 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 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 Has your dog ever bit a person?*Check all that apply. No 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 Human Dog Bite HistoryVictimAgeMale/FemalePart of body bitMedical treatment needed?Stitches?Why do you think it happened? Any additional comments about HUMAN dog bite history ?* Your Dog and OthersIs your dog social with other dogs?*Check all that apply. Seems to love all dogs Good with small dogs Good with large dogs Good if hes OFF leash only Selective Tolerant – ok as long as they don’t sniff him Not sure Has your dog EVER bitten another dog ( not including playbiting , or mouthing )*Check all that apply. No 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 DOG historyUse this comment area below if additional space is needed Dog VictimSize/AgeMale/FemalePart of body bitMedical treatment needed?Stitches?Why do you think it happened? Additional dog bite comments: Lifestyle/TrainingWhere does your dog sleep?*In his crateOn the couchIn my bedOutsideAnywhere he wants tooWhat type of exercise does your dog get?* None Daily walk off my property Plays in my yard Indoor fetch Other Does your dog attend doggie daycare?* Yes No Do you go to dog parks?* Yes No Is your dog food driven?* Highly food driven Moderately food driven No Other What type of collar has EVER been used on your dog?*Check all that apply Buckle collar Martingale Choke chain Prong collar Shock collar Invisible fence collar Do you use a retractable leash?* Yes No Do you use a harness on your dog?* Yes No Is there a place to attach the leash at the dogs chest?* Yes No Check 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 guests Excessive energy Excessive barking Other If you feel your dog is aggressive or fearful please explainHow did you hear about us?* Vet Referred by client Referred by word of mouth Referred by family Dog rescue Dog shelter Online google search Facebook Have you worked with any other dog trainer or dog school with this dog in a group or privately?* Yes No What trainer have you worked with?*The following questions DO NOT mean we are recommending this.*Are you considering rehoming your dog?* Yes No Please explain why you would/would not rehomeAre you considering euthanizing your dog?* Yes No Please explain why you would/would not euthanizeIs there anything else you would like to tell us about your dog and its behavior?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*Date Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
