Intake Form

Please list the animals, excluding the people, in the household.

Name

Species

Breed

Age Obtained

Age Now

Sex/Altered?

Describe your dog's relationship to the other animals in your home (e.g. friendly, hostile, fearful).

Approximately how much time does your dog spend each day without human companionship?

What type of area do you live in?

What type of home do you live in?

Have you moved recently?

If so, how long ago?

Has your household (people or animals) changed since acquiring your dog?

If yes, please describe:

DOG'S BACKGROUND

How many guardians has this dog had, other than you?

If you are not the dog's first guardian (other than the breeder), why was this dog given up?

Why did you choose this dog / breed?

At what age was this dog spayed/neutered?

Why was this done? Or why not?

If your pet is intact, has s/he ever been bred?

Were there any behavior changes after spaying/neutering?

Are you planning to breed?

DIET AND DAILY ROUTINE

What is your dog's energy level, in general:

What is your dog's appetite, in general:

What do you feed your dog? Please be specific, e.g. brand name:

Has your dog's appetite changed?

When are your dog's meal times?

What is your dog's favorite treat?

How much do you feed? (Please be specific).

Who feeds the dog?

How do you exercise your dog and how often?

Do you have a yard?

How do you play with your dog? What toys does your dog have?

Is your dog housetrained?

If yes, how reliable is s/he and at what age did s/he become reliable?

Where does your dog sleep at night? (Please be specific)

Have there been any changes in your dog's sleeping habits?

Where is your dog when alone in the house?

Where is your dog when you have guests?

How does your dog behave while you are leaving home?

How does your dog behave when you return home?

Is your dog accustomed to a muzzle?

Muzzle comments (dog's experience with muzzle, type of muzzle you use, why or why not accustomed to muzzle):

TRAINING EXPERIENCE

What basic manners training has your dog had?
NoneTrained at homeStarted a training class but didn't finishGraduated basic training classGraduated two or more levels of training classPrivate trainerOther:

Please list the trainer(s) or behaviorist(s) you have worked with for this dog:

If your dog has had prior training, rate how much you have used the following methods to teach your dog a new behavior. Use a scale from 0 to 5, with 0 meaning, "I have never used this method" and 5 meaning, "I have used this method a lot."

Dog is placed into position manually.
Dog is lured into position.
Dog is shaped into position using a clicker or verbal marker like "yes!"
Behavior is captured using a clicker or verbal marker.
Dog is punished with a leash correction for not obeying a command.
Dog is punished using an electric collar for not obeying a command.
Dog is verbally punished for not obeying a command.
Dog is ignored for not responding to a cue.

How old was the dog when basic manners training started?

Who in the family is the primary trainer?

List what you consider your dogs top 5 trained behaviours:

Has your dog had any dog sport, hunting, or Schutzhund training?
YesNo

If yes, describe:

SURVEY OF AGGRESSIVE BEHAVIORS

Please fill out this section even if you do not currently have any concerns about your dog’s behavior toward people. This information is essential for me to evaluate and consider before I decide whether the type of training plan I might offer is advisable or feasible.

How does your dog react under the circumstances described below? Please use one of these behavior descriptions (if applicable) to characterize the worst of your dog’s reactions. If you do not feel comfortable doing some of these things, by all means, don't do them! Some of the things on this list are not recommended for any dog.

NA - not applicable

NR - no negative reaction

BR - bark or whine

GR - growl

SL - snarl/bare teeth

SB - snap/bite

Pet dog

Hug dog

Kiss dog

Lift dog

Call off furniture

Disturb while resting/sleeping

Touch while eating

Take dog food away

Take biscuit / cookie

Take real bone

Take toy

Approach when dog has any object/toy/bone

Verbally punish

Physically punish

Leash correction

Stare at dog

Leave room

Reach toward dog

Put leash or collar on / take off

Bathe dog

Groom/brush dog

Dog at groomers

Trim nails

Dog at veterinary clinic

Unfamiliar adult enters house or yard

Unfamiliar child enters house or yard

Familiar adult enters house or yard

Familiar child enters house or yard

Response to toddlers/babies

Dog in car at gas stations, drive-thru windows

Unfamiliar adult approaches guardian, dog on leash

Unfamiliar child approaches guardian, dog on leash

Unfamiliar dog approaches guardian, dog on leash

Dog in house, sees people outside

Response to other dogs, while not on leash

If you'd like to comment on any of the above items, do so below.

Has your dog ever acted aggressively toward a human?
YesNo If No, click here to skip to the bottom. Otherwise, answer the questions below.

Which of the following describes an aggressive episode for your dog?
Attacks are sudden and surprisingEpisodes appear unprovokedThe dog is abruptly docile after an episodeThe dog appears sorry afterwardsThe dog appears disoriented afterwards

Total number of bites (that did or did not break skin)

Number of bites that have broken human skin

Total number of episodes of aggression (growling, snapping, biting)

Describe his behavior in detail (i.e. does dog growl, lunge or bite, and in what circumstance?)

If the dog is in the above situation 10 times, in how many of those times is aggression seen?

What parts of the body has the dog bitten and how severe were the injuries?

Who is/are the target(s) of aggression?

Describe the biting your dog did as a puppy (including play)

How old was your dog the first time he/she growled at a person (not in play)? Describe the circumstance.

How old was your dog the first time he/she snapped or bit at a person? What was the circumstance?

Any other questions or comments for us? Please write them here!

Thank you for taking the time to complete this form. We look forward to working with you. Now go get yourself something tasty as a reward!

This Canine Behavior Questionnaire and Aggression Screen have been expanded and modified by Cindy Peacock from Grisha Stewart, who modified it from the original “Canine Behavioral History” form published by the Cornell University College of Veterinary Medicine. Animal Behavior Clinic, College of Veterinary Medicine, Cornell University Ithaca, NY 14853-6401. The Cornell University’s original form may be found at: http://www.vet.cornell.edu/abc/canine_history.htm

Please fill out the following questionnaire so that we can have a better idea of what is happening for you and your dog.

GENERAL INFORMATION

HOME ENVIRONMENT

DOG'S BACKGROUND

DIET AND DAILY ROUTINE

TRAINING EXPERIENCE

DOG'S BEHAVIOUR

DOG'S MEDICAL HISTORY

PROBLEM BEHAVIORS

SURVEY OF AGGRESSIVE BEHAVIORS