Behavioral Questionnaire

CLIENT INFORMATION

Your Name*

Referred By

Street Address

City

State

ZIP

Phone*

Your Email*

DOG INFORMATION

Dog Name*

Breed*

Gender*

Current Age*

Age Obtained*

Acquired From

If rescued, where from?

If other, please describe...

Veterinarian Name

Veterinarian Phone

City where veterinarian is located:

Spayed/Neutered?

If planning, date when scheduled...

If completed, how old was your dog?

Any changes following procedure?

Specific Medical Conditions

If yes, please list...

Current medication name(s) and corresponding condition...

RESIDENTIAL HISTORY & HOME ENVIRONMENT

Describe your neighborhood

Have you moved since acquiring your dog?

Have there been any changes in the household since acquiring your dog?
Death Birth Marriage Divorce Others moving in/out Changes in schedule

Describe your home

Do you have a yard?

Do you have a patio or deck?

List all the people living in the home, including children (please include child ages - you may select more than one age range)

Describe how your dog gets along with each family member

List all other pets living in the home (please include species, breed, gender & age)

Describe how your dog gets along with other animals living in the home (play together, fight, sleep together, etc...)

Where does your dog sleep at night?

Where does your dog stay when left alone? (when humans aren't home)

Has your dog been crate-trained?

TRAINING HISTORY

Please list and describe any previous training and methods used (classes, private training, other...)

Does your dog offer or know of any of the following?
Sit Stay Down Walk on loose leash Heel Come when called Wait at doors Not to touch things when asked to

Which motivators does your dog respond to?
Food Toys/Games Praise/Petting No rewards given

List any situations in which your dog is less likely to listen to your commands

Is there one specific person that will continue the training plan, or will all members of the family be involved?

A DAY IN THE LIFE OF YOUR DOG

Describe a typical 24-hour period for your dog (including exercise, activities, play, left alone...)

List equipment you use for walking your dog:

Please list food(s) you give your dog, amount and at which time(s) of the day:

How are meals delivered?
Bowl Puzzle toys Hand fed Other

If other, please describe:

List your dog's favorite food, treats, toys, games and activities

DOG BEHAVIOR - Paint a Picture

Describe how your dog reacts to the following:

When your dog is OFF LEASH and sees a FAMILIAR dog (choose all the apply)
wiggles body & wags tail jumps up and down greets other dog barks lunges ignores (walks away) hides/cowers rolls onto back growls snarls snaps

When your dog is OFF LEASH and sees an UNFAMILIAR dog (choose all the apply)
wiggles body & wags tail jumps up and down greets other dog barks lunges ignores (walks away) hides/cowers rolls onto back growls snarls snaps

When your dog is ON LEASH and sees a FAMILIAR dog (choose all the apply)
wiggles body & wags tail jumps up and down greets other dog barks lunges ignores (walks away) hides/cowers rolls onto back growls snarls snaps

When your dog is ON LEASH and sees an UNFAMILIAR dog (choose all the apply)
wiggles body & wags tail jumps up and down greets other dog barks lunges ignores (walks away) hides/cowers rolls onto back growls snarls snaps

Describe how your dog reacts to the following (Please use the following word(s) to help describe your dogs behavior. Choose all that apply. If you are uncertain, you may leave blank and we will discuss it further during the consultation)

Familiar people at your home
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Familiar people away from home
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Strangers that come to your home
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Strangers away from your home
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

When YOU are near your dog's food/toys
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

When you (or other people) take away food/toys from your dog
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

When other dogs are near your dogs food/toys
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Near joggers/cyclists/skateboards
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Near cars/trucks
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Near cats/squirrels
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Near children running and playing
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Near people in uniform
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

During visits with the veterinarian
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Loud noises
wiggles body & wags tail jumps up and down whines barks lunges growls snarls snaps has bitten hides/cowers ignores (walks away) no problem

Please indicate your dogs response to the following:

Petting
freezes growls snarls snaps bites no aggressive response haven't tried

Handling face/muzzle
freezes growls snarls snaps bites no aggressive response haven't tried

Handling paws
freezes growls snarls snaps bites no aggressive response haven't tried

Grooming
freezes growls snarls snaps bites no aggressive response haven't tried

Nail trimming
freezes growls snarls snaps bites no aggressive response haven't tried

Bathing or toweling off
freezes growls snarls snaps bites no aggressive response haven't tried

Physically waking up from resting spot
freezes growls snarls snaps bites no aggressive response haven't tried

Physically or verbally removing from furniture
freezes growls snarls snaps bites no aggressive response haven't tried

Pick dog up
freezes growls snarls snaps bites no aggressive response haven't tried

Restrain dog
freezes growls snarls snaps bites no aggressive response haven't tried

Putting on or removing collar/harness/leash
freezes growls snarls snaps bites no aggressive response haven't tried

Reaching for or grabbing collar
freezes growls snarls snaps bites no aggressive response haven't tried

Staring at your dog
freezes growls snarls snaps bites no aggressive response haven't tried

Using force to get your dog to respond to a command
freezes growls snarls snaps bites no aggressive response haven't tried

Reprimanding in loud voice
freezes growls snarls snaps bites no aggressive response haven't tried

Visually threatening with hand or object
freezes growls snarls snaps bites no aggressive response haven't tried

Hit dog
freezes growls snarls snaps bites no aggressive response haven't tried

Has your dog ever growled at, snapped at, or bitten another animal or person?

If yes, please describe in detail, including any medical treatment required

REASON(S) FOR CONSULTATION

Check all that apply:
No specific problems - just need basic good manners Advancing Skills Jumping Up Door Dashing Behavior issue(s) house-training chewing/mouthing inappropriately barking (incessant) digging pulls on leash on leash barking towards other dogs on leash barking towards people shy or appears withdrawn when around unfamiliar people or places appears 'scared' before being left alone (pacing, whining, panting, not taking food, clinging to owner/family) other

If you selected "Other" - please describe...

For specific behavior issue, please describe and go to next section of questions.

Age of onset

When did the problem start?

How often does the problem behavior occur?

Has the situation become worse, better, or changed?

How long does each incident last?

Since onset, have there been any changes in the pattern of behavior problem, including: how often it occurs, intensity, or time episode lasts?

Have you or anyone else noticed any specific triggers that cause your dog to behave in this manner?

Can your dog be interrupted when engaged in behavior?

Describe any methods used so far to stop the behavior

Describe any changes in behavior since providing help?

Please provide detailed description/date of last time this problem occurred

CLIENTS GOALS and WISH LIST

Please provide three answers to each of the following three questions. If unsure, just list the first thing that comes to mind. You may re-evaluate and make changes at any time.

I love when my dog:

I wish my dog wouldn't:

I wish my dog did:

On behalf of The Inquisitive Canine, I thank you for your time, and for being such a responsible and loving dog guardian!

Please enter the following into the box below & press Submit: