Behavioral Problems Online Application - Dogs

INFORMATION ABOUT YOU

Date:   Referred by:
Name:
Email:
Address:
City:  State:  Zip:
Home Phone:  Work Phone:

INFORMATION ABOUT YOUR PET

Where did you obtain this pet?  ( Breeder   Friend   Pet shop   Humane Society   Other)

Age Pet Was Obtained: 

If you are not the first owner, describe previous home (if known):

Name, age, gender & breed of other animals in the household:

Veterinarian:

ABOUT YOUR BEHAVIOR CONSULTATION

Do you prefer to meet:     At our facility     In your home     At The Aggressive Dog Class

Preferred Days/ Time Range:
(this does not guarantee your preferred time slot, but we will do our best to accommodate your needs. See schedule for the date of the next Aggressive Dog Class) 

What is the primary problem you are seeking help for? 

How would you describe the severity of this problem? (Mild, Moderate, Severe, Other) 

Is euthanasia a possibility if this problem is not solved?

Describe the problem, beginning with the most recent incident, going back through the last 3 incidents:

How often has this occurred in the past
a) Month:   b)  3 Months:    c) Year:   d)  Total: 

Has there been a change in frequency or severity? 

What age was your pet when the problem first started? 

Were there any changes in the household when the problem first appeared?

What has been done so far to try to correct the problem?
Solution attempted            How long did you try this?         What was dog’s response?
                  
                  
                  

Which if any of these techniques have had any success?

Which if any of these techniques have made the problem worse?

What do you think is the reason for your dog's problem?

Have you received advice from anyone about this problem? If yes, please describe:

Please list any additional comments regarding the principal problem:

ENVIRONMENT/LIFESTYLE

For what purpose was this pet obtained (Companion, protection, show, etc.)?

When is pet fed? By whom?
Location pet is fed:
Favorite treat:   Desire for treat: Exceptional   Mild   Moderate   Strong

List household members, ages of children under 18, a short schedule, & how dog gets along with each one.

Amount and frequency of exercise/play: 

Describe where your dog stays (i.e. in the house or in the yard) and how the dog is confined (i.e. crate, tie-out, kennel, unconfined) at each of the following times:

When the owner is home:

When the owner is away:

At night:

When guests visit:

How long is the dog home alone on the average day?

Problems when left alone:   Barks     Destructive     House soiling     Other:

Reaction prior to departure:
Unconcerned   Disappointed   Nervous/Anxious   Frantic     Other:

PREVIOUS TRAINING

Describe any obedience training:Group lessons     Private training     Other:

At what age?   With which family member(s)? 

Success:           Excellent             Good               Fair                  Failed              Didn't Complete

What commands work best?    Which work poorly?

Which family members have most control?    Least control? 

Describe your dog's learning ability:  Fast      Slow     Easily distracted     Other: 

Describe your dog’s personality: 

Does your dog object to being handled or touched?  Y    N
If so, describe:

How does your dog react to:
Other dogs on property?  Ignores      Plays      Barks      Attacks     Other:
Other dogs off property?  Ignores      Plays      Barks      Attacks     Other:
Loud noises?   No reaction     Startles; recovers quickly     Startles, recovers slowly     Hides
Sudden movements?
No reaction     Startles, recovers quickly     Startles, recovers slowly    Defensive

Has your dog:
Shown aggression towards family members while:                                     Dog’s reaction:

Petting             Growl     Bark     Snap     Grab     Glare     Bite, breaking skin
Eating or playing with toy      Growl    Bark     Snap     Grab     Glare     Bite, breaking skin
Being approached when sleeping
Growl     Bark     Snap     Grab     Glare     Bite, breaking skin
Punishment/discipline       Growl     Bark     Snap     Grab     Glare     Bite, breaking skin

Shown aggression towards non-family members while:                               Dog’s reaction:

Entering home                  Growl     Bark     Snap     Grab     Glare     Bite, breaking skin
Entering yard                     Growl     Bark     Snap     Grab     Glare     Bite, breaking skin

Describe the circumstances of any affirmative answers to the above,  including apprx. dates & severity:

Describe any other situations not previously discussed in which the dog has been aggressive:

During aggressive displays, does your dog exhibit any of the following:
Cowering?     Ears back?     Tail tucked?     Hackles raised?     Retreating?     Hiding?

Aside from the principle problem, does your dog exhibit any other problem behaviors?    Yes    No
Describe:

MEDICAL             Please answer the following or have your veterinarian attach a brief medical history.

Has your dog had medical problems?    Ears     Hips    Back     Skin     Allergies   
Other:

Describe:

What medication is your pet currently taking, and for what reason?

How does your dog react to:
                Nail trimming? 
                Giving medication?
                Bathing? 

I hereby authorize Positive Approach to release any recommendations given as a result of this inquiry to my veterinarian. 

I Agree     I Don't Agree