The information you provide is important in diagnosing and treating your pet’s behavior problems. Please fill out this form as completely and accurately as possible. If additional space is required, please attach a separate sheet.

General Information

Name Date of consultation

Address

Phone numbers: Home ( ) - Business ( ) -

Veterinarian/clinic

Referred by (if other than veterinarian)

How many people live in your household?

Ages of children?

Pet Information

Name

Breed

Weight Age Sex M/F

Neutered? Y/N Age neutered

Any change after neutering?

Where did you obtain this pet?


Describe your dog’s personality

nervous    Y / N   playful   Y / N  
obeying    Y / N   pushy   Y / N  
shy    Y / N   stubborn   Y / N  
submissive    Y / N   kindly   Y / N  
under active    Y / N   hyper active   Y / N  


Principal Complaint

For secondary problems see following pages. It is not necessary to duplicate previous answers.

What is the primary problem(aggressive, house soils, destructive, barking, etc.)?







What age was your pet when the problem started?


How often does the problem occur?

Environment/Lifestyle

Age obtained

How often is your pet fed?

Where fed?

Favorite treat?

How often do you walk your pet?

How long?

Off leash?

Does your dog play with other dogs on the walk?

On leash?

Amount of frequency of play

Favorite toy? Favorite game?

Where does your dog sleep?

What is the favorite place of your dog in the house?

What is the favorite place of your dog in the yard?

How long is the dog home alone each day?

Dogs reaction when left alone?

Reaction prior to departure?

Reaction at homecoming?

Is the dog ever alone outdoors?   Y / N   How often?

Are there any other pets in the house?



Training

Have you been to a puppy class? Y / N

Have you been to a obedience class? Y / N

What commands are most successful?

In what locations/situations are commands most successful?

What commands are lest successful?

In what locations/situations are commands least successful?

Have you ever used a halter (e.g. Promise?/HaltiTM) for training? Y / N



Punishment
How does your dog react to the following?

Physical punishment (hitting)

Noise punishment (shaker can/siren)

Ultrasonic (PetAgreeTM)

Water Sprayer

Verbal

Physical handling

Muzzle grasp

Roll-over

Pinning

Time-out


What punishment is most effective?


Does any punishment make the problem worse?   Y / N  


Crate Training

Have you ever used a crate for confinement Y/N If yes, when?

Do you still use a crate? Y/N

When and why did you stop?

Was the crate used for punishment?    Y / N   Crate location?
Handling
How does your dog react to the following?

Nail trimming

Giving medication

Cleaning ears

Grooming
Bathing

Patting head

Rubbing belly

Being lifted

Rolling over

Grasping collar

How does your dog react to

Familiar dogs on property

Familiar dogs off property

New dogs (on property)

New dogs (off property)

Strangers (on property)

Strangers (off property)

Strangers arriving indoors

Other animals




Aggression

If aggression is the principal problem, also complete the following.

Does your pet ever threaten or act aggressive in any of the following situations?
Petting   Y / N  
Grooming   Y / N  
While eating   Y / N  
Chewing objects   Y / N  
Approach when sleeping   Y / N  
Punishment/discipline   Y / N  
People entering home   Y / N  
People entering yard   Y / N  
People off property   Y / N  
Other dogs on property   Y / N  
Other dogs off property   Y / N  
Other animals   Y / N  


Is your dog possessive of food?   Y / N  

Is your dog possessive of toys?   Y / N  


Describe any other situations where your dog barks threateningly



Describe any other situations where your dog growls



Has your dog ever bitten hard enough to break the skin or cause injury?   Y / N  


Was there an illness or health problem when the aggression started?


Does handling a particular part of the body lead to aggression?


When your dog is aggressive, what is your response?








Additional Problems
Describe briefly if not previously discussed.
Destructive digging   Y / N  
Destructive chewing   Y / N  
Barking   Y / N  
Howling   Y / N  
Whining   Y / N  
Housesoiling: Urine   Y / N  
Housesoiling: Stool   Y / N  
Stool eating   Y / N  
Chasing   Y / N  
Hunting/Predation   Y / N  
Jumps on (owners)   Y / N  
Jumps on (guests)   Y / N  
On furniture where not permitted   Y / N  
In rooms where not permitted   Y / N  
Garbage raiding   Y / N  
Food stealing   Y / N  
Pushy-wants own way   Y / N  
Disobedient-runs away   Y / N  
Won’t come when called   Y / N  
Only listens when it feels like it   Y / N  
Sexual habits-masturbation   Y / N  
Roaming   Y / N  
Mounting   Y / N  
Urine marking   Y / N  
Chews/Licks self   Y / N  
Tail biting   Y / N  
Fly chasing   Y / N  
Uncontrollable urination when excited   Y / N  
Uncontrollable urination when frightened   Y / N  
Bedwetting (while sleeping)   Y / N  
Eats non food items   Y / N  
Licks objects   Y / N  
Sleep disorders   Y / N  
Excitability   Y / N  
Overactive   Y / N  
Phobias (thunder/cars, etc.)   Y / N  
Shyness/timidity-non aggressive Describe   Y / N  
(e.g. ears back, cowering, tail tucked, shaking, retreating, hiding, etc.)
Additional problems (not listed)


Please have your veterinarian complete and return your dog’s medical information along with any recent laboratory tests.

I Hereby give permission to Centennial Animal Hospital to phone my Veterinarian’s clinic to verify my dog’s vaccination status (D H L L P - C, Rabies, Titers)

(Please Initial): ___________

Trainer reserves the right to refuse training any dog that is obviously sick or overtly aggressive. Trainer cannot guarantee each individual dog’s ability to learn and/or understand signals, commands, or cues. Trainer reserves the option to refer aggressing dogs to other professionals in the field of Dog Training and Behavior.

Liability Release:

Owner agrees that Centennial Pet Boarding and Grooming and its Behaviour Staff and any referring organization and or other participants will not be liable for any damage or loss resulting from failure of the dog to respond to any signals, commands, or cues taught to the dog by Centennial Pet Boarding & Grooming and Behaviour Staff or resulting from counseling, instruction, or advice supplied to owner of dog.

Dog’s behavior now and in the future is solely the responsibility of the owner of the dog. Should any behavior on the dog’s part now or in the future result in damage to property, owner, or persons of some third party, owner agrees to assume full responsibility and liability to such third party for any and all such damage, and to absolve Centennial Pet Boarding & Grooming and its Behaviour Staff and any referring organization and or other participants from any and all obligations to pay such damage to some third party.

All dogs are trained or otherwise handled or cared for by Centennial Pet Boarding & Grooming and its Behaviour Staff and any referring organization and other participants without any liability whatsoever on Centennial Pet Boarding & Grooming and its Behaviour Staff and any referring organization and or other participants for loss or damage from disease, death, running away, theft, fire, injury to persons, other dogs, other animals, or property by said dog, or other unavoidable causes. Adults are responsible for their minors.

Refund policy: No refunds given unless Centennial Pet Boarding & Grooming and its Behaviour Staff permanently cancels classes and or lessons. No refund if owner misses or drops out of classes and or lessons. No pro-rates given for missed classes and or lessons.

I have read the above contract and liability release and agree to all terms and conditions:

Signature of Owner: ________________________ Date: ___________________