Client's Name *

Email *

Cell Phone *

Client's Address

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about Positive Interactions Dog Behavior and Training? *

Dog Information

Name: *

Breed: *

Spayed or Neutered? *

Age of Dog When Acquired: *

Dog's Current Age: *

Where did dog come from? *

Name of breeder/rescue/shelter if applicable

What was your dog's history prior to acquisition, if known? *

What is your dog’s response to changes in the environment or small/sudden noises? *

Does your dog have any difficulty settling within the home? *

After your dog reacts to a trigger (ex. doorbell, delivery person on property, people/dogs walking on sidewalk), how long does it take him/her to recover? *

Medical/Health History

Primary care veterinarian information (provide clinic name and veterinarian name) *

Date of last veterinary visit *

Date of next rabies vaccine? *

Please list your dog’s current medications, supplements, or other treatments. *

Any chronic medical conditions? *

Any current or history of joint pain, allergies, ear infections, vomiting, or diarrhea? *

Type of dog food and how many meals/day do you feed your dog? *

Does your dog have any food allergies or sensitivities? *

Household Information

List occupants of the house including names and ages: *

List other pets (aside from the dog you are seeking help with) including name, species, age, breed, spay/neuter status and their interactions with the dog. *

If you have more than one pet, where are they each fed? *

Do you have a yard? *

Do you have a fence? *

Has your dog ever attended group training classes? *

Have you ever hired a private trainer? *

How do you correct your dog when he/she misbehaves? *

What types of training aides have you used PREVIOUSLY (prong collar, electric collar, head halter, spray bottle, front-clip harness)? *

What types of training aides are you using CURRENTLY (prong collar, electric collar, head halter, spray bottle, front-clip harness)? (copy) *

Is your dog walked daily? *

How often and for how long is your dog walked? *

Does your dog receive any other types of exercise? *

Is your dog crate trained? *

Have there been any changes in your household routine since acquiring your dog (new baby, new job, new house)? *

Current Behavior Problems

Describe the main behavioral concerns for your dog. If aggression is involved, more information will be collected in Aggression and Reactivity section. *

Describe a typical incident. *

How old was your dog when this behavior started? *

Describe any other details surrounding the behavior including location, people or other animals involved, frequency. *

Aggression and Reactivity (if applicable)

Please complete this section if your appointment is related to reactivity and/or aggression. Otherwise, you can skip to the end and Submit the form.

Describe the most recent incident including date, people/animals involved, location.

How did you respond to the incident?

How frequently does this type of incident occur?

What has been done to address the problem?

Has your dog ever bitten a person or animal? *

Does your dog show aggressive behavior (barking, growling, lunging, snapping, nipping, biting) to familiar people during grooming, bathing and/or nail trims?

Does your dog show aggressive behavior (barking, growling, lunging, snapping, nipping, biting) to familiar people during hugging, kissing, and/or being picked up?

Does your dog show aggressive behavior (barking, growling, lunging, snapping, nipping, biting) to familiar people during verbal and/or physical discipline?

Does your dog show aggressive behavior (barking, growling, lunging, snapping, nipping, biting) to familiar people around dog food bowls?

Does your dog show aggressive behavior (barking, growling, lunging, snapping, nipping, biting) to familiar people around other objects (toys, bones, dog beds, couch)?

Does your dog show aggressive behavior (barking, growling, lunging, snapping, nipping, biting) to familiar people while moving on furniture with your dog?

Does your dog show aggressive behavior (barking, growling, lunging, snapping, nipping, biting) or reactive behavior (barking, growling, lunging) to people or other animals in the home when around dog food?

Does your dog show aggressive or reactive behavior with familiar visitors to your home?

Does your dog show aggressive or reactive behavior with unfamiliar visitors to your home?

Does your dog show aggressive or reactive behavior on walks when seeing people?

Does your dog show aggressive or reactive behavior on walks when seeing children?

Does your dog show aggressive or reactive behavior on walks when seeing other dogs?

Does your dog show aggressive or reactive behavior on walks when seeing other cars, trucks, and/or bikes?

Does your dog show aggressive or reactive behavior on walks when seeing wildlife?

Dog Information

Medical/Health History

Household Information

Current Behavior Problems

Aggression and Reactivity (if applicable)

Thank you!