Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Home Phone

Employer’s name

First

Last

Employer’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Work Phone

Email *

Preferred local pharmacy: (List Name, Phone, and Fax)

Canine's Name *

Age

Breed

Color

Gender:

M
F

Spayed or neutered:

Spayed
Neutered

Age When Performed

Weight

Date and age when acquired (if known):

Reason for obtaining this dog:

Litter size (if known):

Age when weaned (if known):

Raised indoors or outside (if known):

Indoors
Outside
Third Choice

Describe your dog’s personality:

Has your dog been bred?

Yes
No

How much interaction did the puppy have with people in the first year of life?

What method of house training was used?

Your reaction to mistakes during house training:

Was there any interaction with other puppies and dogs? If so, provide details:

Did your dog attend puppy parties?

Yes
No

Are you the dog’s first owner?

Yes
No

Family Veterinarian/Clinic Name

Phone:

Fax

Date of last veterinary visit:

The most recent set of vaccinations received and date:

Date wormed:

Referred by:

Provide medical history (infection/surgeries) and prescribed treatment:

Current/Regular Medications (Such as allergy, Heartworm, herbal, over the counter, pain medication, supplements, topical flea and tick treatment):

Provide route administered (oral, topical, eyes, ears, etc.) and frequency.

Has there been any change in drinking?

Yes
No

Details

Has there been any change in eating?

Yes
No

Details

Have you noticed any of the following?

Coughing
Sneezing
Vomiting
Diarrhea

Has your dog ever been treated for its behavior in the past? If so, describe the treatment and medication (if applicable):

Yes
No

Does your dog have seizures or has it ever had any seizures?

Yes
No

Current Human Household Members

List age and occupation

Have you owned dogs previously?

Yes
No

Have you owned this breed of dog previously?

Yes
No

Have you owned other pets previously?

Yes
No

List current pets in the household: Name, age, breed, spayed/neutered, and relationship with dog

Has your dog ever attended training classes? If so, provide details (where, when, age, handler):

What types of training techniques were used?

How well did your dog do in class? If you were asked to leave, explain why:

How would you rate your dog’s learning ability?

Good
Average
Poor

Does your dog do tricks?

Shake
Rollover

Does your dog pull when on a lead?

Yes
No
Sometimes

Is your dog more obedient with some people than with others? If so, provide details:

How do you correct your dog when he/she misbehaves?

What types of training aids have you used (e.g., pinch collar, prong collar, electric shock)?

Type(s) of food:

Dry
Canned

List brands:

Who is primarily responsible for the feeding?

How much food is given? At what approximate time(s) of day is food given?

Where is the dog fed (physical location)?

Where is the dog fed in relation to other dogs in the household?

Is the dog protective of its food (e.g., does it growl, snap, or bite)? If so, provide details:

Describe your dog’s appetite:

Good
Average
Poor

At what speed does it typically eat?

Fast
Slow

Do you have to be present for your dog to eat?

Yes
No

What are your dog’s favorite foods?

How much water does your dog drink in a day (in pints or liters)? How many water bowls are provided?

Do you add any supplements to your dog’s diet? If so, provide details:

Where does your dog sleep?

If it sleeps on your bed, who invites it up?

When does your dog get up in the morning?

Does your dog ever wake you at night? If yes, how often and do you have any idea why?

When does your dog get to go outside and how long does it like to stay out for?

How does your dog ask to go outside?

Does your dog roam free in the yard?

Yes
No

If the yard is fenced, what type of material is used?

Does your dog run the fence-line barking? If yes, at whom does it bark?

Does your dog enjoy exploring on its own?

Always
Sometimes
Never

What type of exercise does your dog receive? Is this done on or off a lead?

Provide details and the frequency of exercise.

Is there any specific time devoted to play or training on a daily basis?

Yes
No

Does your dog play games with you or other family members? If yes, provide details:

Who initiates play?

Dog
Family

What types of toys does your dog play with?

What does your dog do as you prepare to depart?

Does your dog bark or whine when you leave?

Yes
No

Typically, how long is your dog left alone without human company on any given day?

Does your dog ever vocalize, engage in destructive behaviors, urinate, or defecate while you are away from home?

Vocalizing
Destructive behaviors
Urination
Defecation

What does your dog do during family meals?

Have there been any changes in your household routine (e.g., new baby, change in working hours)? If yes, provide details:

List the five things your dog likes the most (e.g., specific activities, food, toys):

What type of home do you have?

To which areas of your home does your dog have access?

Reaction to handling: Does your dog exhibit any aggression in the following circumstances? This can include growling, snarling, lunging, nipping, snapping, showing teeth, or even biting. If biting occurs, please specify whether tear, puncture, or bruising is involved:

Include how your dog reacts with other people, children, or handlers.

How does your dog behave when visitors come to the house (e.g., barking, door charging)?

Is the behavior different towards familiar and unfamiliar people?

Does your dog display aggression (e.g., growling, snarling, snapping, biting) to visitors inside your home? If yes, provide details:

Does your dog display aggression (e.g., growling, snarling, snapping, biting) to visitors outside your home? If yes, provide details:

Has your dog ever bitten or attacked anyone? If yes, how many times?

Are there any regular visitors to the home? If so, please provide the information requested below this section:

Name, Purpose of Visit, Time / Days of Said Visit, and Dog's Reaction

What is your dog’s response to frequent, occasional, and rare visitors?

Does your dog show inappropriate mounting or other sexual behavior?

Specify whom or what is the target.

Is your dog protective of parts of its body (e.g., ears, mouth, feet)?

If yes, please specify which regions.

Does your dog lick or chew itself more than you would expect?

Yes
No

Does your dog display any reaction to loud noises such as thunderstorms or fireworks? If yes, give details:

Are there any other behaviors that you find objectionable, feel you should mention, or wish to discuss? If yes, describe these:

Describe the problem you are currently experiencing with your dog:

How old was the dog when the problem began?

Is this a chronic (constant) or intermittent problem?

Chronic
Intermittent

Where does the problem commonly occur?

With whom does it occur?

How often does it occur?

If the problem is house soiling, does it occur when you are home and/or away?

If the problem is destructive behavior, does it occur when you are home and/or away?

Additional details about the problem:

Is there any legal action pending because of this dog’s behavior?

Aggression Section (if applicable)

Describe the most recent incident and the setting in which it occurred (be precise):

Where was the dog?

Where was everyone else in relation to the dog?

What was everyone doing prior to the incident?

What was the dog’s body posture (position of ears, tail, face, hair on back)?

What was your reaction or response?

What was the dog’s reaction to your response?

What was the dog’s reaction to your response? Was any form of punishment used? If so, give details:

Was there a bite wound?

Puncture
Tear

Describe the previous three incidents prior to the most recent incident (if any):

How frequently does this type of incident occur?

Does this problem occur when the dog is left alone?

Always
Sometimes
Never

Does this problem occur when family members are present?

Always
Sometimes
Never

What has been done to correct the problem? Has it been getting better or worse?

Do you suspect any cause?

How would you describe your own and your family’s relationship with this dog?

What are your own and your family’s feelings about the dog’s present behavior?

What is your expectation for change?

Under what circumstances would you consider rehoming this dog?

Under what circumstances would you consider relinquishing this dog to a shelter or rescue?

Under what circumstances would you consider euthanasia?

Video recordings of the specific problem behaviors are extremely helpful for verifying your descriptions. Never place any person or animal in danger in order to obtain video information. Feel free to bring the video recordings with you (on your phone, tablet, laptop, etc.) to your consultation. Please do not email videos ahead of time.

Click or drag a file to this area to upload.

Describe what is happening in the video:

Canine Consultation

Canine Consultation Form

Gentle care for peace of mind.

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