Behavioral Consultation About you About your pet Behavior consultation Environment/Lifestyle Previous Training Medical Order Number Information about you Date of Application Referred By Owner's Name * Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Email * Primary Phone * Other Phone (Work/Home/Cell) Information about your pet Pet Name * Pet Breed * Date of Birth Approximate Date Pet Gender * Male - Neutered Female - Spayed Spayed or Neutered * Yes No Age at time of neuter/Spay * Pet Age * Age of Pet when obtained Pet Weight * Where did you obtain this pet? Breeder/Friend/Pet Shop/Humane Society/Other Are you the 1st owner? Yes No Describe previous home (If known): Please list other animals in your household Please list the name, age, gender, and breed of all other animals living in your home. Veterinary Clinic Information about your behavior consultation Do you prefer to meet at * Our facility Your Home The Aggressive Dog Class Range of preferred days & times Your preferred time slot is not guaranteed, but we will do our best to accommodate your needs. Call us for the date of the next Aggressive Dog Class. What is the primary problem that you are seeking help for? (briefly) * How would you describe the severity of the problem? 1 = Mild • 10 = Severe Is euthanasia a possibility if this problem is not solved? No Yes Not Sure Describe the problem, beginning with the most recent incident and going back through the last 3 incidents: * How often has this occurred in the past... One Month? Three Months? One Year? Total Times? Describe any change in frequency or severity? Pet's age when problem started: Briefly describe any household changes when the problem first appeared: Describe what has been done so far to try to correct the problem: For each give: 1) What was tried, 2) How long tried, 3) Dog's response Which if any of the techniques have had any success? Which if any of the techniques have made the problem worse? What do you think is the reason for your dog's problem? Have your received any advice about this problem? Yes No Include any additional comments about the principal problem: Environment/Lifestyle For what purpose was this pet obtained? * Companion/Protection/Show/Other-Explain When is the pet fed? * Who feeds pet? * Feeding location: * Favorite treat: Desire for treat: 1 = Mild • 10 = Strong List below household members, ages if under 18, brief schedule, and how the dog gets along with each: HH Member name: HH Member name: HH Member name: HH Member name: Age (if under 18) Age (if under 18) Age (if under 18) Age (if under 18) Work or school schedule Work or school schedule Work or school schedule Work or school schedule Relationship with dog Relationship with dog Relationship with dog Relationship with dog Amount and frequency of exercise/play: * Exercise type, Times per week, Length of session, By whom 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 owner is home: * When owner is away: * At night: * When guests visit: * How long is dog home alone on average day? * Problems when left alone: Barks Destructive House soiling other Reaction before departure: Unconcerned Disappointed Nervous/anxious Frantic Other Previous Training Describe any obedience training: * None Group lessons Private training Other Are you working with a particular trainer, and if so, please pick which one. * Angie Jeri Lynn Joy Sam I have not started working with a Positive approach dog trainer. Training at what age? With which family member? Success of training: Excellent Good Fair Failed Did not complete Which commands work best? Which family members have most control? Which commands work poorly? Which family members have least control? Describe your dog's learning ability: Fast Slow Easily distracted Other Describe Describe your dog's personality: Does your dog object to being handled or touched? Yes No 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 any of the following aggressive reactions towards family members in these circumstances: 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 or discipline? * Growl Bark Snap Grab Glare Bite, breaking skin Has your dog shown any of the following aggressive reactions towards family members in these circumstances: 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 of the above, including approx dates & severity: Describe any other situations not previously discussed in which your dog has been aggressive: During agressive displays does your dog exhibit any of the following? Cowering Ears back Tail tucked Hackles raised Retreating Hiding Aside from the principal problem, does your dog have any other problem behaviors? * Yes No Describe other problems: Medical Answer the following questions or have your veterinarian send a brief medical history to Positive Approach. Has your dog had any medical problems? * Ears Back Allergies Hips Skin Other Describe any medications your pet is currently taking, and why: * How does your dog react to nail trimming? * How does your dog react to getting medication? * How does your dog react to 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
