Full Name

Street address

Town

State Zip Code

Phone # Home Work Phone

Email Address

Dog's Name Age Sex

Breed

Name of veterinarian:

Vet's address vet's phone

Dates of last vaccinations and what was given: Rabies: DHLPP

Bortadella:

Regularly given medications: Heartworm flea preventative thyroid

Other: (please describe medication and reason for administration:)

How long have you had this dog?

Where does the dog sleep?

What does the dog eat? (everything, including treats/snacks)

How many times a day is the dog fed?

What kind of games do you play with the dog?

What types of difficulties (if any) are you having with your dog at this time?

Does your dog have any aggression problems with other dogs or people?

Dogs People

When did the problem behavior first begin?

What are the "trigger factors" that cause this display of behavior?

Is it more apt to occur inside outside at the door on your property out in

public or new places in the car at the vets groomers

other?

Please describe as accurately as you can the DOGS BEHAVIOR AND ACTIONS when this
problem occurs.
Especially what the dogs behavior is just before the undesired behavior starts and how the dog behaves immediately after it.

_______________________________________________________________________________

Does it happen more with one member of the family than another?

Please describe as accurately as possible what YOU DO AND WHAT ACTIONS YOU (OR OTHER FAMILY MEMBERS) CURRENTLY USE OR HAVE USED WHEN THIS BEHAVIOR OCCURRS:

What is a “typical" day for the dog?

How many people does the dog live with? If there are children, what are the ages?

Are there other pets? Dogs Cats other

Have you observed any changes in the dogs behavior regarding eating, drinking or sleeping habits? If yes, please describe

.

What kind of training equipment do you normally use on the dog?

If more space is needed to describe a behavior please use the space below: