Dog Behavior Modification Consultation FormClient InformationPlease provide your contact details so we can reach out to you.First NameLast NameCellphone NumberEmail AddressAddressAddress Line 1Address Line 2CityDog InformationTell us about your dog's background.Dog's NameBreedAge (Years)Age when obtainedWhere did you obtain your dog?- Select -KUSA Registered BreederFreelance breederAdvert (social media, newspaper)Shelter / rescueFamily / friendsOtherGender Male FemaleSpayed / Neutered? Yes NoAge when sterilised?Reason for sterilisationAny change in behaviour after sterilisation?HistoryWhat do you know about the dog's parents?Did you see / meet your dog's parents and how did you experience their temperament?What were the living conditions like at the breeder / facility / shelter?Why did you buy / adopt this specific breed of dog?What was your intended function for the dog?SportCompanionshipProtectionExercise partnerFamily petFor my child / partnerWhat do you know about this specific breed?How would you describe this dog's character?Other dogs / pets in the householdNameSpecies / BreedGenderAgeSterilised- Select -YesNoAge when obtainedNameSpecies / BreedGenderAgeSterilised- Select -YesNoAge when obtainedNameSpecies / BreedGenderAgeSterilised- Select -YesNoAge when obtainedDetails of other people in the householdincluding frequent visitors and workers / staffNameRelationship to youHow does this person get on with the petsNameRelationship to youHow does this person get on with the petsNameRelationship to youHow does this person get on with the petsNameRelationship to youHow does this person get on with the petsDoes you dog interact well with (tick all that apply Strange dogs Visitors Men Children Other animalsHas anything changed over the last few months? New neighbours Addition to the family (human and/or animal) Personal circumstances (death / divorce / illness / separation etc) Family or personal traumatic experience (Theft / hijacking / job loss / building / etcLiving ConditionsDescribe your dog's home environment.Tick all that apply: The dog has access to the house The dog can roam freely in the house The dog is restricted to one room only (kitchen / garage / laundry) The dog may lie / climb on to furniture / bed The dog has to sit before getting a treatHow long and often does your dog sleep within a 24-hour period?Where does your dog sleep (tick all that apply) In your bedroom Anywhere in the house Restricted to one room (kitchen / garage / laundry) In the dog's bed In your bedFeeding routine Food left out Once a day Twice a day More than twice a day Food puzzlesHow quickly does your dog eat? Within seconds Within 10 minutes or so Nibbling during the day I have to entice him OtherWhat do you feed your dog(s)? (Specify type, brand, etc)Please describe your dog's average stool (consistency, colour, shape, smell, frequency of elimination)Is your dog posssessive over food bowl / toys / bones? Yes NoCan you easily remove food bowl / toys / bones? Yes NoHow do you behave towards the dog(s) when you prepare to leave the house?How does your dog(s) behave when you prepare to leave the house?Describe how you greet the dog(s) when you return homeWhat role does your pet(s) play in your life?Describe your dwelling / home (size of property, type of fence, can your dog see the street, access to grass, etc)Exercise, Environmental Enrichment, Training & SocialisationDo you take your dog(s) for walks? Yes NoHow long are these walks?Where do you usually walk?Is the dog excited before the walk?Is your dog taken to a safe area where he can run free? How often?How much time is allowed for that?Do you or someone else play with the dog(s)?How often?Describe the type of games (fetch / tug / chase)What is (are) your dog's favourite toy(s)?How does your dog keep himself busy during the day?Does your dog chase squirrels / cats / critters?How does your dog keep himself busy at night?How often does your dog get chew toys?Describe the toys and chewsDoes your dog get food treats? If so, which and how often?Was your dog taken to any training classes? If so, what type of classes, at what age, and for how long?Please supply the name of the training schoolDescribe the type of training (equipment used, reward based, etc)How easy is it to put on your dog's collar / harness and leash?How well does your dog walk on leash?How easy / difficult is it to control your dog inside your home and property?Please tick all that apply:Choose by clicking hereMy dog is an escape artistMy dog barks and growls at strange people and dogs in the home envrionmentMy dog barks and growls at strange people and dogs when out for a walkWhich of these instructions does your dog follow consistently? Sit Down Come Leave it Stay / waitWhat does your dog enjoy most in life?What does your dog enjoy least in life?Does your dog allow you to touch all parts of his body?Is your dog noise sensitive? If so, to what?Known Medical HistoryCurrent Medications / SupplementsHow does your dog cope with vet visits, visits to the grooming parlour, etc?Date of last vet visitDate of last vaccination?General questionsRelationship Is your dog primarily a watchdog and not a family dog? Does any family member take your dog along on short errands? Does anyone share food with your dog during meal times? Does anyone talk to your dog at least once a day? Are you or any other family member aware of your dog's mood? Do you keep photographs and video clips of your dog? Does your household celebrate your dog's birthday?Does your dog eat excrements?OftenSometimesNeverDoes your dog have excessive fear reactions?OftenSometimesNeverDoes your dog lick or scratch excessively?OftenSometimesNeverDoes your dog chase its tails repetitively?OftenSometimesNeverDoes your dog stare at apparently nothing?OftenSometimesNeverOption 4Does your dog pace restlessly up and down?OftenSometimesNeverOption 4Does your dog chase shadows or lights?OftenSometimesNeverOption 4Behavioral Symptoms & ConcernsIdentify and detail the specific behavior issues you are experiencing.Please describe the main problem you wish to addressWhen (how long ago) did this problem first start?Please describe the first incident in as much detail as possibleHas anything changed / happened in or outside your home at approximately the same time the problem behaviour occured?How often does the problem behaviour occur?Please describe the most recent incident in as much detail as possibleWhat have you tried to address the problem and what was the outcome?Are there any patterns to the behaviour (time of day / specific location / playing /going for a walk)How do you react to the behavioural problem (punish your dog / shout / reassure / ignore)Which other problem behaviours would you like to address? Aggression towards humans Aggression towards other dogs Separation Anxiety Leash Reactivity (barking/lunging) Resource Guarding (food, toys, spaces) Fearfulness / Phobias (noises, objects) Excessive Barking Destructive Behaviour (e.g. chewing)In case of AggressionLeave blank if this does not apply to your dogHas your dog bitten an unfamiliar person or dog? Yes NoHas your dog growled at or bitten a family member? Yes NoPlease indicate in which of the following situations your dog tends to growl or bite: When brushed When petted When touched When pushed or shoved When reached for or picked up When threatened When punished Disturbed while sleeping When eatingHow many incidents have there been to date?Has the time between the incidents gotten shorter, longer or stayed the same?What seems to be the trigger for the aggression?Has the aggression progressively gotten less / stayed the same / worseWas any person or pet injured?Describe the physical damage (scratch, bruises, punctured skin, multiple bites, ddep, wound, need for stitches, serious damage that required intensive medical treatment, killed a pet, etc)If a pet or person was killed how many (please specify)Did the aggression happen in the owner's presence or absence or both?Submit Form
