Canine Behaviour Consultation

Assessment form

Please provide as much information as possible, so we can provide tailored advice. This detailed form will take at least 30 minutes to complete, so please ensure you set aside enough time.

First Name

Last Name

Phone

Mobile

Address

For referred cases: Veterinarian’s name & clinic:

Clinic address

How did you hear about our service?

Friend referral Vet referral Google Advertising Facebook Other

Pet's name

Pet's weight (Kg)

Pet's date of birth

Sex (Male/Female)

Neutered (Yes/No)

Age neutered

Any changes after neutering?

Breed

Age obtained

Colour

Where did you obtain this pet?

Breeder's details (if applicable)?

Describe previous home(s) if known?

For what purpose what your pet obtained?

Behaviour of parents or littermates (if known)?

Briefly describe your dog’s personality (e.g., quiet, confident, excitable, unruly, bold, stubborn, etc.)

How often is your pet fed?

Type of food

When are they fed?

Type of treat(s)?

How often do you give treat(s)?

When do you give treat(s)?

List of any supplements?

List all other pets, including species, breed, age, and sex:

Describe how your pets get along with each other:

List each family member living in the home (include sex and age of children):

Describe briefly how your pet gets along with each family member including any problems:

What is your dog’s favorite reward?

If you could give your dog ANY food as a reward, what would be the favorite? List the top five:

Other than food, what rewards (e.g., toy, affection) would be most enticing to your dog? List the top five:

Type of exercise/play:

Who exercises/plays?

How often/how long?

Favorite game(s):

Favorite toy(s):

Where is your dog’s favored sleeping spot?

Where does the dog sleep at night?

Have you ever used a crate for confinement? Y/N If yes, describe crate and location

Describe the dog’s reaction to being crated?

Do you still use a crate? Y/N If no, when and why did you stop?

Briefly describe the usual daily schedule for the family:

Has this pet had obedience training?

Training type?

Describe training classes your dog has had (including trainer’s name if applicable):

Type of training collar used ?

Please indicate type:

Pet's response?

Success with collar

How would you describe the training?

Briefly describe the training techniques:

What training was most successful?

What training was least successful?

Describe your dog’s learning ability:

Is there any ongoing training?

List family member(s) with MOST control:

List family member(s) with LEAST control:

Sit

Sit-stay 1 minute

Sit-stay 5 minutes

Sit-stay 10 minutes

Down

Down-stay 1 minute

Down-stay 5 minutes

Down-stay 10 minutes

Come (indoors)

Come (in yard)

Come (in park)

Heel (with no distractions)

Heel (WITH distractions)

Give/Drop

Does your dog know any tricks?

Can you get your dog to settle on command?

Have you ever used physical punishment

Pet's reaction?

Noise punishment (shaker can/siren):

Pet's reaction?

Ultrasonic:

Pet's reaction?

Water sprayer:

Pet's reaction?

Verbal reprimands:

Pet's reaction?

Physical handling: Muzzle grasp:

Pet's reaction?

Physical handling: Pinning:

Pet's reaction?

Time-out:

Pet's reaction?

Booby traps/repellants:

Pet's reaction?

Does punishment make the problem worse?

If YES, describe:

Has punishment ever led to threatening behavior or aggression?

If YES, describe:

Dog responds differently to punishment from different family members?

If YES, describe:

Nail trimming

Brushing

Rubbing belly

Grabbing collar

Rolling over

Being lifted

Bathing

Patting head

Teeth brushing

Ear cleaning

Giving pills

Giving liquid medications

Hugging/kissing

Where is your dog’s primary location for elimination?

URINATE: How many times a day?

DEFECATE: How many times a day?

Is your dog completely housetrained?

Yes - continue to NEXT section No - complete the rest of this section

Does your dog ever eliminate outdoors?

Yes No

Do you accompany your dog to its elimination site?

Yes No

What is YOUR DOG's favored location outdoors?

What is YOUR favored location outdoors?

What do you do after your dog eliminates in the correct location?

What do you do when you catch your dog soiling in an incorrect location?

Does your dog signal to eliminate?

About how often does your dog housesoil?

When is the dog most likely to housesoil?

Does your dog soil in the home by:

Urinating Defecating Both

What are the most likely locations for indoor elimination?

Does your dog housesoil when family members are at home?

Does your dog housesoil while you are watching?

What do you do when you find urine or stool in the improper location?

Does your dog urine mark?

Does your dog ever eliminate in a location where they have been sleeping?

Yes No

Does your dog ever leak/dribble urine?

Yes No

Do you ever confine your dog to a crate?

Yes No

If YES, does your dog ever eliminate in the crate?

Yes No

Uncontrollable urination when excited?

Yes No

Uncontrollable urination when frightened?

Yes No

Does urine leak while your dog is:

Sleeping? Walking? Approached by owners? Approached by stranger?

If this is a referred case, can your veterinarian complete the medical section of this questionnaire?

Type of appetite?

Does your pet have any arthritis or other painful conditions?

Have you noticed any deficits in your pet’s senses?

Does your pet drink or urinate excessively?

Stools:

Urine:

Does your pet have normal bowel movements?

Does your pet have any other medical problems?

Is your pet presently on any medication?

Has your pet had any laboratory tests (blood, urine, X-rays, etc.)?

When you go out is your dog confined or crated?

How long is the dog left alone on the average day?

At what time of the day is your dog left alone?

How does your dog react when you prepare to leave?

Has your dog ever been left at a kennel, veterinary office, or with a friend/relative?

Is the dog ever alone outdoors?

How often?

How long for (average)?

Where is the dog left when outdoors?

How does your dog react to being left alone outdoors?

Does your dog exhibit any behavior problems when you leave it alone?

NO - proceed to Reactivity section YES - continue with this section

Describe your dog’s behavior when left alone at home (list problems and how long after departure they occur):

Does the behavior differ depending on length of time or time of day left alone?

How does your dog react at the time of departure (as the last person prepares to leave)?

Does the behavior differ depending on who is the last to leave?

What is the dog’s reaction at homecomings?

Have you ever left the dog alone in the car? If YES, how does it react?

Reaction to familiar dogs ON property