Behavior Questionaire

General Information

*Pet's Name:
*Your Name:
*Address:
*City:
*State:	* Zipcode:
*Email:
*Phone	( )

Pet Information

Is your pet spayed or castrated? Yes No

If so, at what age?

Reason for neutering:

If your pet is not neutered, do you plan to breed? Yes No

Has this dog ever been bred? Yes No

How old was your pet when you first aquired it?

Has this pet had other owners?

How long have you had this pet?

Where did you aquire this pet?
stray/found	breeder	rescue/shelter
newspaper adoption ad	petstore	friend
other

Why did you get this dog?

Date your dog was last vaccinated?

Was a rabies vaccination given at this time? Yes No

Veternarian information:

Name:
Clinic Name:
Address:
Phone:

How long have you used this veterinary hospital?

Is this pet (check all that apply):
allowed to run free, unsupervised	fenced/kenneled
leash-walked only	indoors only
outside, unleased and supervised	outdoors only

What percentage of the day does your dog spend
inside: outside:

What kind of living situation do you have?
Apartment/Townhouse/Condo House with small yard	House with large yard Farm
Other

How many times is your dog walked or let out per day?

How long is each walk?

How often is your dog fed meals per day?

How often is your dog fed treats per day?

How often is your dog fed snacks from the table per day (people food) ?

What brand/type of dog food is fed to your dog?

Does your dog have any allergies? Yes No

If yes, please specify:

Does your dog have any preexisting or current medical issues?
Yes No

If yes, please specify:

Is your dog currently on heartworm prevention? Yes No

Is your dog taking any other medications? Yes No

If yes, please list:

Do you have any other pets in the home? Yes No

If yes, are any of them ill? Yes No

Has your household changed since aquiring this dog? Yes No

If so, how?
death of human in family death of pet in family divorce marriage baby born	child moved pet added family moved family schedule changed
other

List humans, including self, currently living in the home.
Name	Sex	Age	Relationship

Please list pets living in the home and indicate order aquired.
Order	Name	Breed	Sex	Age

Do you know how many animals were in this dog's litter?
Yes No

If so, total? Females: Males:

Why did you choose this specific dog from the litter or rescue?

Why did you choose this specific breed?

Have you had this particular breed before? Yes No

Have you had pets before? Yes No

If so, please list what kind. (cats, dogs, birds, exotics, etc.)

Where does your dog sleep? (check all that apply, dogs move at night)

In your bed
On it's own bed in your bedroom
In a crate in your bedroom
On it's own bed in another room
In a crate in another room
On the floor next to your bed
In another room voluntarily
Anywhere it wants
In another room locked out of yours
Other

How often do you play with toys or play games with your pet inside the house daily?

What types of games do you play?

How often do you play with toys or play games with your pet outside the house daily?

What types of games do you play?

How long do these play sessions last?

Describe in detail how you prepare to leave the house when the dog will be left alone. Do you ignore your pet, do you seek it out and say goodbye, do you make a fuss over it, etc.?

What does your pet do as you prepare to leave? Follow you, hide, stay asleep, run to a crate or door, bite your hands?

What is your dog's obedience history? (check all that apply)
no school	trained by owner	puppy kindergarten
group lessions - basic
group lessions - advanced
private trainer at home
private trainer at facility
other

Age of dog when taking training sessions:

Who took the dog to obedience classes?

How did the dog act/react during the training sessions?

What commands does your dog know and how well?
sit	good average poor
stay	good average poor
down	good average poor
come	good average poor
heel	good average poor
fetch	good average poor
drop it	good average poor
other	good average poor

Has your dog ever bitten a person or attacked another dog?
Yes No

If yes, please explain in detail. What occurred prior to bite/attack? How log did the attack last? What were the injuries? What occurred post bite/attack?

Does your dog have a bite record? Yes No

If yes, in what state?

Please list the last two situations that caused your need for behavior counseling. Give details and context of the situation.

List all of the issues that you would like to cover at the consultations.

Refered by:

By checking this box I acknowledge that all of the information in this form is correct to the best of my knowledge and consider this my electronic signature to this form. *

The participationand consistency of ALL family members is very important to the process and outcome of these proceedings. Full committment is required.

All Things Canine LLC • 8113 E. 124th Street South • Bixby, OK 74008 (918) 527-WOOF • www.tulsadogbehavior.com