THIS FORM IS CURRENTLY BEING REVISED AND IS NOT WORKING CURRENTLY
CALL 602-769-1411
|
Drug | Mg strength | Frequency (e.g. once a day, twice a week) |
Length of time drug administered (e.g. days, 2 weeks, etc.) |
Outcome (successful or not) |
List any other dietary treatments, supplements or
remedies and the dogs response:
FAMILY / RELATIONSHIPS | ||||||||||||||||||||||||||
List each family member: (including sex and age) |
||||||||||||||||||||||||||
Name: | Sex: | Age: | ||||||||||||||||||||||||
Male Female |
||||||||||||||||||||||||||
Male Female |
||||||||||||||||||||||||||
Male Female |
||||||||||||||||||||||||||
Male Female |
||||||||||||||||||||||||||
Male Female |
||||||||||||||||||||||||||
Male Female |
||||||||||||||||||||||||||
Male Female |
||||||||||||||||||||||||||
How does your dog get along with each member of the family? |
||||||||||||||||||||||||||
Who feeds? | ||||||||||||||||||||||||||
Who plays? | ||||||||||||||||||||||||||
Who grooms? | ||||||||||||||||||||||||||
Who gives treats? |
||||||||||||||||||||||||||
Who trains? | ||||||||||||||||||||||||||
Describe the family schedule, including how long the dog is left alone: |
||||||||||||||||||||||||||
List all the pets in your household:
|
||||||||||||||||||||||||||
How do the pets get along with each other? |
TRAINING | |||||||||||||||||||||||||||||||
Any formal training? YES NO Class Private Instructor Trained at home |
|||||||||||||||||||||||||||||||
How successful was training? |
|||||||||||||||||||||||||||||||
Is there any ongoing training? YES NOIf yes, describe: |
|||||||||||||||||||||||||||||||
Type of training collar used: (check one) |
Dog’s response: | ||||||||||||||||||||||||||||||
Neck collar | |||||||||||||||||||||||||||||||
Remote collar (if yes, indicate type e.g. shock, citronella, etc.) |
|||||||||||||||||||||||||||||||
Head halter (Gentle Leader®, Halti®) |
|||||||||||||||||||||||||||||||
Body harness | |||||||||||||||||||||||||||||||
Other (pinch, prong) |
|||||||||||||||||||||||||||||||
How would you describe the training?
Reward-based Assertive/domineering |
|||||||||||||||||||||||||||||||
How well does your dog obey the following commands (when asked for the FIRST time) for each household member? (list as a percent) |
|||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||
Is there any other commands or tricks your dog knows? |
PUNISHMENT | ||
Have you ever used any of the following for punishment? |
YES/NO | Reaction |
1. Physical punishment? | YES NO | |
2. Noise punishment (shaker can, siren) | YES NO | |
3. Ultrasonic (Petagree®) | YES NO | |
4. Water Sprayer: | YES NO | |
5. Verbal reprimands: | YES NO | |
6. Physical handling: muzzle grasp | YES NO | |
pinning |
YES NO | |
7. Time out: | YES NO | |
8. Bobby traps/repellents: | YES NO |
HANDLING | |||
How does your dog react to the following types of handling? |
|||
Nail trimming: | Giving pills: | ||
Brushing: | Hugging/kissing: | ||
Rubbing belly: | Patting head: | ||
Grabbing collar: | Lifting: | ||
Rolling over: | Bathing: |
MEDICAL SCREEN | |||||||||||||||||||||
Is there any past illness or present illness currently under treatment? |
|||||||||||||||||||||
Any apparent painful conditions? YES NO |
|||||||||||||||||||||
Describe appetite: Voracious Normal Finicky Decreased |
|||||||||||||||||||||
Any changes in stool? YES NO |
|||||||||||||||||||||
Any changes in drinking? More Less Same |
|||||||||||||||||||||
Any change in urination? Same More frequently Less frequently Larger volumes Smaller Volumes |
|||||||||||||||||||||
Any food tolerances? YES NOIf so, what? |
|||||||||||||||||||||
Is your pet on any other medications? (besides the drugs listed under primary behavior complaint if any)
|
REINFORCER ASSESSMENT | |
If your dog was allowed any treat, what would it prefer? (List top five) |
|
1. | 2. |
3. | 4. |
What other types of rewards does your dog enjoy? (play toys, walks, attention / affection). List top five: |
|
1. | 2. |
3. | 4. |
HOUSETRAINING SCREEN (Skip this section- if your pet is not housesoiling, ) |
|
Was your dog ever completely housetrained? YES NO |
|
At what age was he/she considered housetrained? |
|
How often does your pet housesoil? (i.e. several x/day, weekly, or monthly, etc.) |
|
Is it urine, stool or both? |
|
When is the dog most likely to housesoil? |
|
Do you have a doggie door? YES NO |
|
Does your dog use the doggie door? YES NO |
|
In what rooms does your dog tend to soil? |
|
Is there a room/location in which the dog does NOT soil? |
|
Does your dog soil when when family members are home? |
|
Does your dog soil directly in front of a family member? |
|
What do you do when you find urine or stool in an improper location? |
|
Does your dog urine mark? (urinate on upright objects) |
|
How many times per day does your dog have a chance to go outside to eliminate? |
|
How long is the longest confinement without access to outside? (if any) |
|
Is your dog crated? YES NO Is there urine in the crate? YES NO |
|
Does your dog leak urine when: Sleeping Walking Approached by owner If approached by a stranger Excited Frightened |
DEPARTURE BEHAVIOR SCREEN | |
How long is the dog left alone on an average day? |
|
Is the dog left: Outdoors Access to both |
|
Is your dog crated or confined on departure? YES NO |
|
If crated, describe crate: Location of crate? |
|
If confined other than a crate, please describe: |
|
Has your dog been left at a kennel, veterinary clinic or with family/friends? If yes, describe your dogs reaction: |
|
Does your dog exhibit any problem behaviors on your departures? YES NO |
|
If no please skip this remaining section; If yes continue with the following questions. |
|
Describe your dog’s behavior when left alone: |
|
Does the behavior differ depending on the length of departure or the time of day left alone? |
|
How does your dog act as you or other family members are getting ready to leave? Describe: |
|
Does the behavior differ depending on who is the last to leave the home? |
|
How does the dog react when the family returns? |
|
Have you ever left the dog alone in the car? If so how did it react? |
AGGRESSION SCREEN | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Has your pet displayed any of the following?
Threatening display? |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Skip the next section if your pet has displayed any of the above, but they have been resolved, or controlled to your satisfaction. |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Skip this section and move to the next if your pet is not aggressive towards people. |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Aggression Towards People |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
In your opinion, what is the potential for injury to another person? |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Has your dog ever bitten hard enough to break skin or cause injury? YES NO If yes, describe: |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Number of bites that have broken skin: |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Body parts typically bitten: |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
If your dog has bitten a person, how old was the dog the first time he/she bit? (months or years) |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is your dog ever aggressive to members of the immediate family? YES NO If yes, who? Describe: |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is your dog ever aggressive to visitors in your home? YES NO If yes, who? Describe: |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is your dog aggressive to people off your property? YES NO If yes, where the people known, strangers or both? Explain: |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is there a particular person or type (age, sex, uniforms) that your dog is most likely to threaten or bite? |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is there a particular location or situation where aggression is most likely to occur? |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
When your dog threatens, attempts to bite or bites, how do you handle the situation and what is the dog’s reaction? |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
How would you describe your dog’s expression and postures at the time of aggression? (hackles raise, ear forward, tail back, tail up or tucked between legs and under, cowering, running forward and then retreating): |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Skip this section and move to the next if your dog is not aggressive towards other dogs. |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Aggression Towards Other |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
In your opinion, what is the potential for injury to another dog? |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
How old was your dog when you first noticed aggression to other dog(s)? (months or years) |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Has your dog ever bitten hard enough to break skin or cause injury requiring medical attention? YES NO |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Number of bites that have broken skin |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Body parts typically bitten: |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is there a particular location or situation where aggression is most likely to occur? |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
SUBMIT QUESTIONNAIRE | |
LIKE US ON FACEBOOK
|Home| |Phoenix Dog Training| |Puppy Training| |Phoenix Dog Trainer|Severe Behavior Problems |Phoenix Dog Behaviorist|Aggressive Dog Training| |Anxiety and Phobic Dog Training| |Service Dog Training| |About Phoenix Dog Training| |Phoenix Dog Trainer Reviews||Phoenix Dog Training Blog|Dog Training Services Valleywide|Glendale Dog Training|Scottsdale Dog Training |$50,000 Charity Dog Training Challenge |Contact Phoenix Dog Training|Cities and Zip Codes we Serve|