Questionnaire

Your Name (required)

Your Email (required)

Pet's Name

Breed

Date of Birth

Sex
 Male Female

Spayed/Neutered
 Yes No

Address (Required)

City (Required)

Zip Code (Required)

Phone (Required)

What is the main behavior problem or complaint?

Additional Problems?

How frequently does the problem (or problems) occur (how many times daily, weekly or monthly)?

Chronology of the behavior problem

When did you first notice the main problem (age of dog)?

When did it first become a serious concern?

In what general circumstances does the dog misbehave?

Has the problem changed in frequency? (please describe)

Has the problem changed in intensity? (please describe)

Has the problem changed otherwise?

Describe several examples in detail:

Most recent incident
Date:

Second to last incident
Date:

Third to last incident
Date:

Other significant incidents:

What have you done so far to try to correct the problem?

How do you discipline your dog for this and for other misbehavior?

Home Environment

Please list the people, including yourself, living in your household. Please include ages of children

Please list all animals in the household including patient: (Include Name, species, breed, sex, age obtained, age now)

In what sequence were the above animals obtained? (Please number animals in the table above)
What is your dog's relationship to the other animals? (eg. friendly, hostile, fearful?) Please describe:

What type of area do you live in? (City/town, Suburbs, Rural)

What type of house do you live in? Please describe

Have you moved since acquiring your dog?
 Yes No

How many times?

Has your household (people or animals) changed since acquiring your dog?
 Yes No

Please describe:

Dog's Background

Why did you decide to get a dog?

Why did you choose this breed?

Where did you get this dog? (SPCA, Breeder-newspaper ad/flyer, Breeder-referral, Pet store, Friend, Stray, Other)

Have you owned dogs before?
 Yes No

If known: how many littermates? (Males, Females)

How many animals to choose from?

Why did you choose this dog over the others (please be specific)

Was a temperament test performed?
 Yes No Unsure

Result:

Describe your dog's behavior as a puppy:

Do you have any news about littermate behavior? (Please describe)

Did you meet the parents?
 Yes No

If yes, please descibe their behavior:

Has this dog had other owners?

How many?

Why was the dog given up?

At what age was your pet neutered/spayed?

Why was this done?

Were there any behavior changes after neutering?

If your pet was "intact" has he/she ever been bred?
 Yes No

Are you planning to breed?
 Yes No Unsure

If you have an intact female, when was her last heat? Was it normal?

Diet and Feeding

What do you feed your dog? (Please be specific, eg. brand name)

Has your dog's appetite changed?
 Increased Decreased No Change

How much do you feed? (Please be specific)

Who feeds the dog?

Location:

What's your dog's favorite treat?

Daily Schedule - Typical 24hr day

Please describe a typical 24-hour day in your dog's life:

How does the dog behave with familiar visitors?

How does the dog behave with unfamiliar visitors (children or adults)

How do you exercise your dog?

Is the dog free in a fenced yard?
 Yes No

Is the dog tied outside?
 Yes No

Does the dog run free?
 Yes No

How do you play with your dog?

What toys does the dog have?

Is your dog housetrained?
 Yes No

How was the dog housetrained?

Does your dog ever eliminate in the house?
 Yes No
 Urinate Defecate

Where does your dog sleep at night? (please be specific)

Does your dog sleep (more, less, same)?

Where is your dog alone in the house?

Where is your dog when you have guests?

How does your dog behave while you are leaving the house?

How does your dog behave when you return?

Obedience Training

What basic obedience training has your dog had?
 None Trained at home Started obedience classes but didn't finish Graduated obedience class once Graduated obedience class two or more levels Private trainer
Other:

What type of training tools have you used (choke chains, prong collar, head halter, shock collars, treats)? Do you currently use any of these?

How old was the dog when obedience training started?

Who in the family is the primary trainer?

Does your dog have any awards or titles? (Please describe)

Has your dog had any hunting, herding, protection, attack or Schultzhund training?

What percent of the time does your dog obey the following commands, for each member of the family: (Sit, down, stay, come, heel, don't pull)

Does your dog know any tricks? (Please describe)

Have you exhibited your dog in breed shows?
 Yes No No but I plan to

Does your dog jump up on you or others without permission?
 Yes No

Does your dog paw at you or at others?
 Yes No

Does your dog lick you?
 Yes No

Does your dog mount people?
 Yes No

If yes, whom does he or she mount?

Does your dog mount other animals or objects?
 Yes No

Does your dog ever bark at you?
 Yes No

Does your dog bark at other times?

What is your dog's activity level in general?
 Low Average High Excessive

Medical History

Is your dog on any medication now, for this or other problems?

Has your dog been on medication in the past?

Date of the most recent rabies vaccination:

Aggression Screen

GR - Growl
SL - Snarl/bare teeth
SB - Snap/bite
NR - No reaction
NA - Not applicable

1. Pet Dog
2. Hug Dog
3. Kiss Dog
4. Lift Dog
5. Call off furniture
6. Push/Pull off furniture
7. Approach on furniture
8. Distrub while resting/sleeping
9. Approach while eating
10. Touch while eating
11. Take dog food away
12. Take human food away
13. Take water dish away
14. Take rawhide
15. Take biscuit/cookie
16. Take real bone
17. Take toy/object
18. Approach when dog has any object/to/bone
19. Verbally punish
20. Physically punish
21. Visual threat
22. Speak to dog (normal tone)
23. Stare at dog
24. Bend over dog
25. Push on shoulders or back
26. Approach dog near spouse
27. Enter room
28. Leave room
29. Reach toward dog
30. Leash restraint
31. Collar restraint
32. Scruff restraint
33. Put leash on/take off
34. Put collar on/take off
35. Bathe dog
36. Towel dog
37. Groom/brush dog
38. Dog at groomers
39. Trim nails
40. Leash/collar correction
41. Response to "sit"
42. Response to "down"
43. Dog at veterinary clinic
44. Unfamiliar adult enters house or yard
45. Unfamiliar child enters house or yard
46. Familiar adult enters house or yard
47. Familiar child enters house or yard
48. Response to toddlers/babies
49. Dog in car at tollbooths, gas stations
50. Unfamiliar adult approaches owner, dog on leash
51. Unfamiliar child approaches, dog on leash
52. Dog in house, sees people outside
53. Response to other dogs, while on leash
54. Response to other dogs, while not on leash

Where are you on a scale of 1 to 5 as follows
 1. I am here only out of curiosity - problem is not serious 2. I would like to change the problem, but it is not serious 3. The problem is serious and I would like to change it, but if it remains unchanged that's all right. 4. The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog. 5. The problem is very serious and I would like to change it, if it remains unchanged I will have my dog euthanized or give him/her up.

For Aggression (Towards people) (Skip this section if aggression is not the problem)

Please answer yes or no to these characteristics of your dog's behaviour:

Attacks are sudden and surprising
Episodes appear unprovoked
The dog is abruptly docile after an episode
The dog appears "sorry" afterwards
The dog appears disoriented afterwards
Episodes are associated with a "glazed" or "absent" expression
I can usually tell what will set off my dog
The aggressive behaviour is new and uncharacteristic

Has your dog bitten and broken skin?
 Yes No

Number of bites that broke skin

Total number of bites (that did or did not break skin)

Total number of episodes of aggression (growling, snapping, biting)

Describe typical episode (eg. does dog growl, lunge or bite, and in what circumstance)

If the dog is in the above situation 10 times, in how many of those times is aggresion seen (eg. all=100%, just one=10%, etc.)

What parts of the body has the dog bitten and how severe were the injuries?

Who is/are the target(s) of aggression?

Did your dog bite as a puppy?
 Yes No

If yes, please describe, including age

How old was your dog the first time he/she growled at a person?

What was the circumstance?

How old was your dog the first time he/she snapped or bit at a person?

What was the circumstance?

Commitment to Training

How much time are you willing to spend working with your dog daily/weekly?

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End of questionnaire. Thank you!