Case History Questionnaire - SUNDOGS Canine Consultation and Training

This survey will gather a little information about you and your dog prior to your consultation visit. It shouldn't take too long, maybe about 10 or 15 minutes. Please note that your answers are confidential and will be e-mailed to you as confirmation. We look forward to hearing from you and discussing your training needs!

Client Information

* Name

* Street

* City

* State

* ZIP

Phone

* Email

Occupation

Dog Information

* Name

Age

Breed

Mixed breed? If so, what?

Current Weight

* Gender M F

* Spayed / Neutered Yes No

How did you hear about Sundogs?

Be as specific as possible

Other, please specify

Personal Referral, please specify

Current Issues

Primary Issue

What is the PRIMARY issue you wish to address?

How frequently does the problem occur (how many times daily, weekly, or monthly)?

When did this become a concern?

How much of a problem do you consider these behaviors to be? Very Serious Serious Not Serious

What interventions have you used so far to correct the problem(s) ?

Has the problem changed in intensity or frequency?

If this issues cannot be resolved, what would you do?

I have a second issue Yes No

Issue #2

What is the SECOND issue you wish to address?

How frequently does the problem occur (how many times daily, weekly, or monthly)?

When did this become a concern?

How much of a problem do you consider these behaviors to be? Very Serious Serious Not Serious

What interventions have you used so far to correct the problem(s) ?

Has the problem changed in intensity or frequency?

If this issues cannot be resolved, what would you do?

I have a third issue Yes No

Issue #3

What is the THIRD issue you wish to address?

How frequently does the problem occur (how many times daily, weekly, or monthly)?

When did this become a concern?

How much of a problem do you consider these behaviors to be? Very Serious Serious Not Serious

What interventions have you used so far to correct the problem(s) ?

Has the problem changed in intensity or frequency?

If this issues cannot be resolved, what would you do?

I have a fourth issue Yes No

Issue #4

What is the FOURTH issue you wish to address?

How frequently does the problem occur (how many times daily, weekly, or monthly)?

When did this become a concern?

How much of a problem do you consider these behaviors to be? Very Serious Serious Not Serious

What interventions have you used so far to correct the problem(s) ?

Has the problem changed in intensity or frequency?

If this issues cannot be resolved, what would you do?

Behaviors - check all that apply

Check all behaviors that apply: Not Housetrained
Barks
Destructive
Bites
Doesn't obey
Chases
Runs Away
Escapes
Mouthy
Growls
Separation Anxiety
Assertive
Jumps up
Attacks Dogs
Attacks People

Check all behaviors that apply: Demanding
Fearful
Defensive
Anxious
Food Thief
Eats Stool
Gets on Furniture
Eats Stuff
Chews
Pushy
Digs
Howls
Submissive
Predatory
Shy

Background

Where did you get your dog?

>> Other, please specify

Breeder information

Did you see the facility? Yes No

Meet mom? Yes No

Meet Dad? Yes No

When did you get your dog, (approximate date)?

Has your dog had other owners? Yes No

>> How many other owners?

How many littermates did your dog have (if known)? # Males # Females

Why did you choose this particular dog over others you were considering (in litter or shelter)? Please be specific.

Do you have any knowledge of litter-mate behavior either while your dog was with his/her litter or since s/he has left the litter? Yes No

>> Please specify

What age was the spay neuter operation done?

Did you notice behavioral changes after spaying/neutering? Yes No

>> What Changes?

For INTACT dogs

At what age was her first heat?

What date was her latest heat?

Was it normal? Yes No

Does he mark with urine (leg lifting)? Yes No

>> What age did this begin?

>> Where does he mark? Inside the home Outside the home

Are you planning to breed your dog? Yes No Unsure

Home Environment

Please list all PEOPLE who live in the household with your dog, including age and gender (256 chars left)

Does the subject dog have specific problems with any PERSON listed previously? Yes No

>> With whom? and What problem(s)? (128 chars left)

If you have multiple pets, where in aquisition order does this dog fall?

Please list all other PETS in the house, including species, age, and gender (256 chars left)

Does the subject dog show favoritism toward any PERSON listed previously? Yes No

>> Whom?

Does the subject dog have a specific problem with any PET listed previously? Yes No

>> Which one(s)? Please describe the problem(s). (255 chars left)

Have there been any changes to the dog's home or surrounding environment recently? Yes No

>> Please list those changes (e.g., construction, move, birth / death of family member, etc.) (255 chars left)

What type of home do you live in? Single Family
Condo
Apartment
Townhouse

Does your dog need an elevator or stairs to access the outdoors? Yes No

What is your neighborhood like?

Do you have a fenced yard? Yes No

>> What type of fence (check all that apply)? Chain link
Privacy
Invisible
Other

>> Please specify other

Where does your dog stay during work days? (mark all that apply) X-pen
Doggie Daycare
Indoor kennel run
Crate
Tied out
Free roam indoors
Sequestered in a room
Fenced yard

Daycare information

Which Doogie Daycare facility?

At what age did your dog start attending Daycare?

How many days per week?

How does the dog travel to day care?

How many TOTAL hours a day is your dog left alone on a typical weekday?

How many CONSECUTIVE hours a day is your dog left alone on a typical work day?

Daily Schedule

Describe a typical WEEKDAY in your dog's life (time up, feeding (when?), play, exercise, toileting times, evening hours, bedtime routine - be specific) (256 chars left)

Describe the DIFFERENCES in a typical WEEKEND DAY in your dog's life (be specific) (256 chars left)

Activities

Describe what activities your dog does for exercise while under supervision (256 chars left)

How does your dog experience outside time? (check all that apply) Tie-out
Fenced yard
On leash
Invisible fence
Unfenced area, no barriers
Long line
Dog park
Other

>> Please specify other

Do you use a dog walker? Yes No

>> Who?

How much time does your dog spend outside daily?

Supervised or alone?

Dog's activity level:

Does your dog play off leash with other dogs? Yes No

Please describe what play style(s) you observe: (wrestling, mounting, mouth playing, chase games, etc.) (256 chars left)

What methods or games do you use to mentally stimulate your dog? (128 chars left)

How much time (minutes, hours) each day do you devote to exercising your dog?

How much time per day does your dog get to run (not walk)?

Who in your family exercises your dog?

What is your dog's favorite toy?

Where is your dog's favorite place to be stroked?

Rest and Sleep

Where in the home is your dog's favorite place to rest?

Is your dog crate trained? Yes No

>> What type(s) of crates? Plastic / nylon Wire

Does your dog seek out his resting area (crate or bed) of his own free will ?

During the day:

During the night:

Where does your dog sleep at night?

Have you noticed changes in your dog's sleeping habits? Yes No

>> Please specify what changes

House Training

Is your dog house trained? Yes No

>> What methods were used to house train your dog?

>> Does your dog ever have elimination accidents? Yes No

>> Describe the occasions/locations your dog eliminates in the home:

Urine:

Feces:

Boarding

Has your dog ever been boarded? Yes No

>> Where, and for how long?

>> Did your dog have behavioral changes upon returning home? Yes No

>> Please describe the changes

Training Basics

Equipment you have ever used on your dog (check all that apply) Buckle Collar
Martingale / limited slip collar
Body Harness
No-pull Harness
Prong / Pinch collar
Head Halter
Chain Training Collar
Electronic Collar
Choke Chain
Other

>> Other - please specify

What equipment are you currently using with your dog?

Has your dog had any training? (check all that apply) No training
Trained at home
Started class, didn't finish
Finished one class
Finished two or more levels of class
Private, in-home trainer
Other

>> Other, please specify (herding, protection, bite training, etc.)

Please check all the methods of training used: Positive Reinforcement
Leash Correction
Verbal Correction
Choke chain
Chain training collar
Electronic collar
Other

>> Other, please specify

How old was your dog when you started training him/her?

Who in your family is the primary trainer?

Grade the following based on reliability

Recall (come)

Leash walk w/o pull

Sit

Stay

Leave it

Down

Drop it

Heel

Does your dog obey the above cues more often for one family member than others? Yes No

>> Whom?

Does your dog know any tricks? Yes No

>> Which ones?

What cues would you like your dog to learn or do better? (check all that apply) Sit
Down
Stay
Wait
Go to place/bed/mat/crate
Loose leash walking
Recall (come)
Leave it
Polite Greeting
Drop it
Other

>> Other, please specify:

In what way(s) do you discipline/correct your dog for unwanted behavior? Be specific.

Diet and Feeding

What do you feed your dog (brand(s))?

Do you feed both wet food and kibble? Yes, mixed
Yes, separately
No

How many cups per day?

Divided into how many meals?

Food is: Available at all times (free fed)
Given at specific times

Does your dog receive food/vitamin supplements? Yes No

>> Please specify

Who feeds your dog?

Where does your dog eat?

Describe your dog's eating habits (e.g., picky, voracious, gulping, etc.)

Does your dog get treats? Yes No

>> Types(s) and brand(s)

What is your dog's favorite treat (be specific)?

How many treats per day?

Who gives your dog treats?

Medical / Health History

Does your dog have ANY previous or current medical condition or health issue, no matter how minor they seem? Yes No

>> Please specify the health issues

Does your dog have any pre-existing condition that may have an impact on training? (E.g. hip dysplasia, sight loss, hearing loss): Yes No

>> Please describe the pre-existing condition(s)

Is your dog on flea preventative? Yes No

Is your dog on heart worm preventative? Yes No

Date of last rabies vaccine

Is your dog currently taking ANY OTHER medications? Yes No

>> Please specify what other medications:

What was the date of your dog's last full veterinary physical exam?

Behavioral History

When your dog eats dog food from her food bowl, describe how she would act if :

You approached your dog

You reached for the bowl

You picked up the bowl

If your dog has long-lasting treats (like a chew or pig ear), how she would act if:

You approached your dog

You reached for the treat

You picked up (or took) the treat

Toys

Is your dog possessive of toys? Yes No

>> Please describe the circumstances

How does your dog react to visitors to the home? Please explain in detail:

KNOWN people

UNKNOWN people

Where is your dog when KNOWN visitors knock on your door?

Where is your dog when UNKNOWN visitors knock on your door (salespeople, FedEx, plumbers, etc.)?

How does your dog react when visiting the vet? Please explain in detail:

Does your dog...

Jump up on you or others without permission? Yes No

Lick you or others? Yes No

>> Whom?

Paw at you or others? Yes No

>> Whom?

Mount people? Yes No

>> Whom?

Mount other animals or obejcts? Yes No

>> Please describe:

Ever bark at you? Yes No

>> Please describe:

Ever bark at other people? Yes No

>> Please describe:

Ever cower (or turn belly up) in anyone's presence? Yes No

>> Please describe:

Ever urinate in anyone's presence? Yes No

>> Please describe:

Describe how your dog behaves while you are preparing to leave home

Describe how your dog reacts when you return home

Does your dog exhibit fear, phobias, or other unusual behavior? Yes No

>> Please specify to what: (thunderstorms, loud noises – specify which ones, shadows, reflected lights, etc.)

What experiences make your dog uncomfortable or stressed? Noises Strangers Cars in drive Some other dogs Thunderstorms Movement (arms/hands) Being yelled at Shock fence Vet Hospital Your stress Knocking Other

>> Other, please specify:

Biting

* StartBiteHistory

* StartBiteHistoryDog

* Has your dog bitten another dog? Yes No

Bite History - bitten another dog

* On or Off leash? On Off

* Has there been more than one incident? Yes No

* Did the bite(s) draw blood from the other dog? Yes No

Specifics

* Number of punctures * Number of stitches

* Number of visits to repair damage to other dog

* What body parts were bitten, in detail?

* Where did the incident occur?

* StartBiteHistoryByDog

* Has your dog been bitten by another dog? Yes No

Bite History - bitten by another dog

* On or Off leash? On Off

* Has there been more than one incident? Yes No

* Did the bite(s) draw blood from the other dog? Yes No

Specifics

* Number of punctures * Number of stitches

* Number of visits to repair damage to other dog

* What body parts were bitten, in detail?

* Where did the incident occur?

* StartBiteHistoryHuman

* Has your dog bitten a human? Yes No

Bite History - bitten a human

* On or Off leash? On Off

* Has there been more than one incident? Yes No

* Did the bite(s) draw blood? Yes No

Specifics

* Number of punctures Number of stitches

* Number of visits to repair damage

* What body parts were bitten, in detail?

* Where did the incident occur?

Conclusion

What do you wish to accomplish in this consultation? (256 chars left)

Veterinary Information

What is the name of your dog's regular Veterinary Office or Clinic:

Name of Veterinarian

Phone number Fax

Office Address City ZIP

I hereby give permission to Peggy Bowers of Sundogs to contact my Veterinarian’s Clinic to verify my dog’s vaccination status (D.H.L.L.P.-C, Rabies) (Please Initial):

I hereby give permission to Peggy Bowers of Sundogs to discuss, if necessary, my dog’s behavior with my veterinarian and/or clinic/office staff (Please Initial):

I hereby give permission to Peggy Bowers of Sundogs to discuss, if necessary, my dog’s behavior with my dog's daycare staff and/or dog walker (Please Initial):

I hereby give permission to Peggy Bowers of Sundogs to discuss, if necessary, my dog’s behavior with any previous pet trainers I have used (Please Initial):

Your responses have been submitted; you should receive an email as confirmation.
Thank you for considering Sundogs for your dog's training needs. You will be contacted shortly.