Preliminary Behavioral History Intake Form

Information obtained is from this form is only for the purpose of assisting individual pet owners.
All information is kept confidential and will not be distributed to third parties.

Owner Information

Your Name: Phone: City State:

 E-mail: Best time of day to contact you by phone:

Referred by:

  Dog Information

 Name: Age Sex Neutered? Breed:  

Age obtained How acquired 

Date of last vet visit   Reason for visit and Outcome:

Describe medical issues,  medication or supplements to the diet such as vitamins or nutriceuticals

  

What are your dog's favorite games and toys?

How many times a day do you feed your dog?    How Much?  

Who feeds?     Brand of food:

  Where does your dog sleep?  

Is there anyplace in the home that is off limits to your dog?   

Where does the dog spend most time?

What kind of living situation do you have?   How often is your dog walked?

General  - Check all that apply:

  Jumping  Mouthing Pulling on leash Mounting House soiling Excessive Barking

  Destructive Chewing Copraphagia Pica Unruly Runs Away Digging Shy or fearful

Submissive urination Aggressive to humans, dogs or other animals Guards toys, food bowl or other items Other

Training History

 What type of training has your dog received?  

If trained yourself, how did you learn to train?

What type of collar do you use to train your dog?  Slip or choke Prong or pinch Head Halter Harness Buckle collar Other

What is the main behavioral problem?  Describe in detail, including a chronological list of events.

What have you done to try and correct the problem?

Additional Comments or Concerns

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