Behavioral Questionnaire - SUNDOGS Canine Consultation and Training

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Case History Questionnaire

Client Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Occupation

Dog Information

Name *

Age

Breed

Mixed breed? If so, what?

Current weight

Gender *

Male
Female

Spayed / Neutered *

How did you hear about Sundogs?

APDT
Peaceable Paws Affiliate List
Peaceable Paws Referral List
Google search
Personal referral
Other

If Other, please specify:

following On Health

Current Issues

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?

Nothing – I’ll live with it
Re-home the dog
Euthanize the dog

I have a second issue

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?

Nothing – I’ll live with it
Re-home the dog
Euthanize the dog

I have a third issue

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?

Nothing – I’ll live with it
Re-home the dog
Euthanize the dog

I have a fourth issue

Issue #4

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?

Nothing – I’ll live with it
Re-home the dog
Euthanize the dog

Behaviors – check all that apply

Check all 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
Demanding
Fearful
Defensive
Anxious
Food theif
Eats stool
Gets on furniture
Eats stuff
Chews
Pushy
Digs
Howls
Submissive
Predatory
Shy

Background

Where did you get your dog?

Breeder information

Did you see the facility?

Meet mom?

Meet dad?

Other, please specify…

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

Has your dog had other owners?

How many littermates did your dog have (if known – total/male/female)?

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?

For INTACT dogs

At what age was her first heat?

What date was her latest heat?

Was it normal?

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

Does the subject dog have specific problems with any PERSON listed previously?

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

Please list all other PETS in the house, including species, age, and gender

Does the subject dog show favoritism toward any PERSON listed previously?

Does the subject dog have a specific problem with any PET listed previously?

Have there been any changes to the dog’s home or surrounding environment recently?

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?

What is your neighborhood like?

Do you have a fenced yard?

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

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?

Describe the DIFFERENCES in a typical WEEKEND DAY in your dog’s life (be specific)

Activities

Describe what activities your dog does for exercise while under supervision

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?

How much time does you dog spend outside daily?

Supervised or alone?

Supervised
Alone

Dog’s activity level:

Very low
Low
Average
High
Very high
Excessive

Does your dog play off leash with other dogs?

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

What methods or games do you use to mentally stimulate your dog?

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?

What type(s) of crates?

Plastic / Nylon
Wire

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

During the day:

Never
Rarely
Occasionally
Often
Always

During the night:

Never
Rarely
Occasionally
Often
Always

Where does your dog sleep at night?

Have you noticed changes in your dog’s sleeping habits?

Please specify what changes

House training

Is your dog house trained?

What methods were used to house train your dog?

Boarding

Has your dog ever been boarded?

Where, and for how long?

Did your dog have behavioral changes upon returning home?

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?

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

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?

Whom?

Does your dog know any tricks?

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?

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?

Types and Brands

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?

>> 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):

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

Is your dog on flea preventative?

Is your dog on heart worm preventative?

Date of last rabies vaccine

Is your dog currently taking ANY OTHER medications?

>> 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 :

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:

If you approached your dog

You reached for the treat

You picked up (or took) the treat

Toys

Is your dog possessive of toys?

>> 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 you dog…

Jump up on you or others without permission?

Lick you or others?

>> Whom?

Paw at you or others?

>> Whom?

Mount people?

>> Whom?

Mount other animals or obejcts?

>> Please describe:

Ever bark at you?

>> Please describe:

Ever bark at other people?

>> Please describe:

Ever cower (or turn belly up) in anyone’s presence?

>> Please describe:

Ever urinate in anyone’s presence?

>> 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?

>> 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

Has your dog bitten another dog? *

Bite History – bitten another dog

On or Off leash? *

Has there been more than one incident? *

Did the bite(s) draw blood from the other dog? *

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? *

Has your dog been bitten by another dog? *

Bite History – bitten by another dog

On or Off leash? *

Has there been more than one incident? *

Did the bite(s) draw blood from the other dog? *

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? *

Has your dog bitten a human? *

Bite History – bitten a human

On or Off leash? *

Has there been more than one incident? *

Did the bite(s) draw blood? *

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? *

What do you wish to accomplish in this consultation?

Veterinary Information

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

Phone

Name of Veterinarian

Fax

Address

Address Line 1

Address Line 2

City

State

Zip Code

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):