Behavior History "*" indicates required fields 1General2Pet3Behavior4Aggression5Nutrition & Exercise6Medical7Training General InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Consultation Date MM slash DD slash YYYY Primary Phone Number*Is this a cell phone? Yes No Secondary Phone NumberIs this a cell phone? Yes No Email* Primary Occupation or Hobby Are you vaccinated against Covid?You don't have to answer. We are asking so we know if we have the option to not wear masks. Yes No Please list who else lives in the home and whether they are adults, children or infants Pet InformationIs this your first dog or puppy? Yes No Other Name of Dog Dog's DOB (if known) or age What breed is your dog? How much does your dog weigh? What is your dog's gender and intact status? Intact Male Neutered Male Intact Female Spayed Female Name, Age, Breed of Other Pets in HomeWho referred you to PBC?*VeterinarianDakin Humane SocietyExercise FinishedSandy Meadow Farms/Missy KielbasaK9 Capers/Heather StaasFriendTrainerOtherPlease list who referred you so we can thank them!* Why did you choose PBC?Good reputation and/or reviewsI liked the websiteQuick response timeCostOtherWhy?* When did you get your dog? MM slash DD slash YYYY Where did you get your dog from? Breeder Shelter Rescue Group Newspaper Ad Store Friend/Acquaintance/Family Member Other Please list the name of the shelter, breeder, rescue group, or other Was everyone in the household on board to get the dog? Yes No How many homes/placements was the dog in before you got him/her? Just the breeder/shelter Unknown Multiple Please tell us more about how many and where BehaviorHow is your dog with general handling?Nail trims, pulling off a tick, bathing, etc. Not good. Will bite/growl/snap/behave aggressively. Tolerates but doesn't like it. Totally fine. Allows anything and everything! Please check off anything that your dog would guard or be possessive of. Space (like a spot on the couch or bed) Bones or food Toys People Property (the house) Crate Nothing If your dog guards, what is the extent of the behavior? Freezing, growling, snapping, biting? Please describe.Please describe the reasons you wanted to have your dog evaluated*Is your dog sensitive to certain sounds? Yes No Please explain in detailIs your dog thunderphobic? Yes No Does your dog chase light or shadows? Yes No Please describe how your dog behaves in the following contexts/situations:In the car Relaxed Stressed Gets sick Sleeps Barks/vocalizes In the car my dog is... Loose In a seatbelt In a crate Other Please describe At the vet Relaxed, allows all parts of exam Nervous but never aggressive, does not require a muzzle Needs to be muzzled for exam Needs sedation in order to be examined With other dogs Loves meeting and playing with all dogs Is neutral and indifferent about other dogs Is afraid of unfamiliar dogs but not aggressive Barks and lunges at unfamiliar dogs Wants to attack unfamiliar dogs Will attack other dogs at home Other Please describe With adults Relaxed and social with all people Indifferent and neutral with strangers Uncomfortable around unfamiliar men Uncomfortable around unfamiliar women Has history of aggressive behavior with strangers Has history of aggressive behavior with primary caretakers With children Unknown, has never been exposed to children Relaxed and calm with all children Relaxed and calm with children in home Nervous or afraid (avoids, flees) Has history of showing aggression towards children Other Please describe Outside Loves the outdoors Would run away if given the chance (must be on leash) Barks a lot at certain stimuli (cars, people, bikes, and/or dogs) Good off-leash, comes when called Nervous, stressed or afraid With cats and/or prey animals Wants to chase Wants to play with the animal Wants to kill the animal Has a history of killing cats, chickens, birds, and/or other prey animals Inside Couch potato Busy, always trying to get attention and get into stuff Destructive Barks out the window a lot Countersurfs When left alone Crated, fine. Crated, stressed. Loose in house, destructive. Loose in house, fine. Never alone. Other Please describe At a kennel/doggy daycare Has never been Always gets good reports, no issues Is stressed but no history of aggression Has been aggressive towards other dogs Has been aggressive towards people Does your dog attend doggy daycare? Yes No Where? How often? Multiple days every week 1-2 days per week A few times each month Rarely When did you first notice the behavior issues? What prompted you to bring in a consultant at this time? What are your goals or hopes for the consultation?Have you considered rehoming or euthanizing your dog? What are your biggest concerns regarding your dog? Biting another dog Seriously attacking or killing another dog Biting a human Seriously attacking a human Having a poor quality of life due to issues Having serious property destruction due to issues Running away Self-mutilation or injury Issues impede ability to have, adopt or foster children Other Please describe AggressionHas your dog ever bitten a person or dog, growled (not play growl) or snarled/showed teeth?* Yes No Since the start of the aggressive behavior, has it...* decreased increased remained the same How do you respond when your dog is aggressive?*How does your dog behave BEFORE an aggressive incident?*How does your dog behave AFTER being aggressive?*Has the dog broken skin (human) by biting?* Yes No List any triggers you've noticed that cause your dog to be aggressive* Nutrition & ExerciseWhat brand of food does your dog eat? Does your dog have any allergies? Yes No How many times do you feed your dog each day? 1 2 3+ What type of treats do you give your dog? Do you leave the food dish down all day? Yes No Does your dog finish all of his/her food right away? Yes No Please check off the types of exercise your dog gets Leash walks Playing in house/yard with other dog(s) Playing fetch, frisbee, etc. with people Playing Find It games inside Off leash hiking/walking Do you own a treadmill? Yes No About how much exercise does your dog get each day? If your dog doesn't get exercise, do you notice a change in behavior? Yes No If you leash-walk your dog, what equipment do you use? Flat collar (buckle collar) Fixed length leash (4-6 feet long) Retractable leash Choke chain collar Prong collar Limited slip/Martingale collar Front clip harness Back clip harness Halti or Gentle Leader E-collar/shock collar Do you have an invisible/electronic fence? Yes No Medical HistoryHas your dog ever been used for breeding purposes? Yes No If spayed/neutered, did the surgery and recovery go smoothly? Yes No Has your dog had any other surgeries? Yes No Please describe any significant medical informationPlease list all medications & supplements, including dosageWho is your veterinarian? Do you consider your vet to be progressive or conventional? I have no clue! Conventional Progressive Other Please describe Do I have your permission to contact them for records? Yes No What form of flea/tick preventative do you use?* Nothing Seresto collar Generic brand flea/tick collar K9 Advantix topical treatment Advantage topical treatment Other topical treatment Holistic/homeopathic treatment Oral treatment such as Nexguard Other Please describe How often do you administer flea/tick and heartworm preventative?* Never Never for flea/tick, year round for HW Never for HW, year round for flea/tick Year round for HW, seasonally for flea/tick Year round for flea/tick, seasonal for HW Seasonal for both (approx. April - October) Year round for both Please indicate if your dog ever tested positive or received treatment for any of the following:* Lyme or tick-borne illness Heartworm Giardia Coccidia History is unknown Has always tested negative Training HistoryPlease list training classes your dog has attended, including the date and location/name of facilityPlease list any other trainers/consultants you've worked with (either with current dog or past dogs)Do I have your permission to contact them for records? Yes No What commands does your dog know? Name recognition Sit Down (lay down) Stand Touch/targeting Tricks Stay Come Heel Off (as in, get off of couch/person/counter) Drop it Leave it Retrieve Wait Find it What methods have you used for training? Lure dog with a treat Push/physically put dog into correct position Leash corrections with choke or prong Clicker or mark & reward training E-collar training (shock or vibration collar) Behavior Adjustment Training (BAT) Corrections for unwanted behavior (water bottle, saying NO, etc.) If your dog does something wrong, how do you handle it?Describe any circumstances where you use physical management with the dog (hitting, rolling, scruffing, etc.)Has the dog been crate-trained? I don't know No Yes, but still hates it Yes, but only tolerates it Yes, loves it Other Please describe Are you currently using a crate with your dog? Yes No In percentages, how well house-trained is your dog (100% being no accidents in house unless very sick) Is there anything else you'd like me to know? Δ
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