Pre-Meeting Initial Consultation Behavioral Questionnaire

CLIENT INFORMATION

Your Name*

Name of additional guardian(s)

Street Address

City

State

Zip

Phone*

Your Email*

Referred By

DOG INFORMATION

Your Dog's Name*

Breed*

Gender*

Current Age*

Age Obtained*

Acquired From

If rescued, where from?

If other, please describe...

Name of your dog's veterinarian:

City where veterinarian is located:

Is your dog spayed/neutered?

If planning, date when scheduled...

If completed, how old was your dog?

Any changes following procedure?

Does your dog have any specific medical conditions?

If yes, please list:

Does your dog currently take any medications, including over-the-counter, vitamins and/or herbal supplements?

If yes, please list:

BITE HISTORY

Has your dog ever bitten another animal?

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

Has your dog ever bitten a person?

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

MAIN REASON(S) FOR CONSULTATION

Check all the apply:
 Basic Good Manners New Puppy New Adult Dog Walking on Leash Jumping up Coming When Called Doorbell Etiquette House-Training Crate Training/Confinement Chewing/Mouthy Barking (incessant) New Baby Separation Distress High Predatory Drive ON-leash dog reactivity/aggression OFF-leash dog reactivity/aggression Sibling rivalry Resource guarding Body handling/grooming Fear of/aggression towards unknown people Aggression towards family members Other

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

For specific behavior issue, please answer the following questions:

Behavior Issue:

Age of onset

When did the problem start?

How often does the problem behavior occur?

Has the situation become worse, better, or unchanged?

How long does each incident last?

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 list what first comes to mind. You may re-evaluate and make changes at any time.

I LOVE WHEN my dog:

I wish my dog WOULD:

I wish my dog WOULDN'T:

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

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