| HISTORY QUESTIONNAIRE DATE: |
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| Owners Name |
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| Your Phone Number |
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| Your Email Address |
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| Do you check this email address often? |
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| Address |
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| City |
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| Names and ages of people in home |
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| Dogs Name |
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| Dogs Age |
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| Dogs Weight |
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| BACKGROUND |
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| How were you referred to us? |
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| Name of Dog? |
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| Breed of Dog? |
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| Where did the dog come from? |
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| (If Adopted) If the dog was given up, do you know why ? |
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| How long have you had the dog? |
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| Have you had previous dog experience? If so, please specify. |
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| Why did you choose this particular breed? |
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| Why did you choose this particular dog? |
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| PHYSICAL & MEDICAL ISSUES |
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| Who is your veterinarian? |
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| Is your dog current on vaccinations? |
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| When was the dog's last veterinary exam? |
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| Does the dog have any known medical problems? |
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| Is the dog on any type of medication? |
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| Is the dog spayed/neutered? If not, plans to do so? |
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| Does the dog have any food allergies? |
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| FEEDING, TREATS & CHEW ITEMS |
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| What type of food is the dog being fed? |
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| How much is he fed, and is the amount measured? |
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| What type of treats, chew items etc. does he/she get, and how often? |
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| If scheduled feedings, at what hours? |
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| Does the dog eat right away and finish the meals? |
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| Where is the dog fed and who is nearby when he eats? |
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| Does the dog get "people food" and at what location? |
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| LOGISTICS |
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| Where does the dog sleep? |
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| Is the dog allowed on the furniture? |
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| Where does the dog eliminate? |
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| For what period of time, on average, is the dog left alone? |
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| Where is the dog kept when no one is home? |
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| How long does it take you to drive to work/ home? |
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| What percentage of the time does the dog spend indoors versus outdoors? |
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| TRAINING |
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| Has the dog had any previous training? Please be as specific as possible. |
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| Describe how you reprimand, correct or punish your dog for unwanted behavior. Please give an example. |
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| Describe how you reward the dog food good behavior. |
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| Name all people who will be responsible for training the dog. |
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| GENERAL INFORMATION |
| What would you most like to change about your dog's behavior? Name at least 3 things in order of importance. |
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| Is the dog housebroken? Crate trained? |
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| What type of exercise does the dog receive? How many minutes a day, average? |
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| What is your dog's favorite toy? Game? Activity? |
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| What is your dog's favorite treat? |
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| BEHAVIOR ISSUES |
| Has your dog ever bitten a person, or another dog? Please describe in detail. |
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| Can you describe other problem behavior(s)? |
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| When did the behavior(s) first manifest? |
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| Were there any changes in the household at the time the behavior first manifested? |
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| How often does the behavior occur? Please specify circumstances, location and who is present at the time. |
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| Has the frequency or intensity of the behavior increased, decreased or remained the same? |
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| When was the most recent incident? |
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| What prompted you to seek help at this time? |
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| What has been done so far to address this problem? |
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| How much time and effort are you willing to spend on resolving this issue? |
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| What days/times are you available for appointments? |
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| Other information that might be helpful to us? |
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THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM!
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