Registration Details
Owner's Name*
Owner's Last Name*
Email*
Date*
City, State, Zip*
Day Phone*
Evening Phone*
Who referred you? Friend, veterinarian, vet staff, rescue group, internet, other
GENERAL INFORMATION
Dog's Name*
Breed*
Age in years (if age is between 6-11 months, state 1 year)*
Sex
Weight
NEUTERED / SPAYED
Select One
Yes
No
Age spayed or neutered
Age Obtained
From where
Select One
Breeder
Pet Store
Shelter
If breeder, what is the name and location of breeder? If pet store, which one? If shelter, which specific shelter?
Purpose for obtaining this pet
Select One
Companion
Protection
Breeding
Show
Other
Behavior of parents or littermates, if known
Describe your pet’s personality
MEDICAL
Describe any current medical problems (i.e. ear infections, hip dysplasia, skin irritations, etc.)
List any medications your pet is currently taking and for what reason
DIET
Type of food
Select One
Dry
Moist
Brand of food
What are the first three ingredients listed on the nutrition label?
Amount of food
How many times per day is dog fed?
Is the dog free fed? (This means that the food bowl is filled and placed on the floor all day long, or until the dog finishes what’s in the bowl.)
Select One
Yes
No
Describe feeding habits
Select One
Poor Eater
Picky
Normal Appetite
Voracious
Treats / supplements
Favorite treat
PLAY / EXERCISE
Describe amount and frequency of play and exercise, and with whom
Pet’s favorite activity
Toys played with
OTHER PETS
Please list other pets in the household, their species, bred, age, sex, whether or not they are neutered or spayed, etc. (Dogs, cats, and any other animals)
Please describe a typical 24 hour period in your dog’s life – start with where and when the dog wakes up in the morning and end with where and when the dog goes to sleep
HANDLING
Nail Trimming
Giving medication (orally and/or eye drops)
Cleaning ears
Grooming
Bathing
Petting head
Rubbing Tummy
Picking up
Rolling Over
SOCIAL BEHAVIOR
Familiar dogs
Unfamiliar dogs
Familiar people
Unfamiliar people
ENVIRONMENT / LIFESTYLE
Do you live in house, apartment, condo, other?
When family is home
When family is away
When family sleeps
When guests visit
How long is the dog home alone on average each day?
Dog’s reaction when left alone?
Dog’s reaction prior to departure?
Dog’s reaction at homecoming?
Percentage of time indoors:
Percentage of time outdoors:
Where is the dog kept when outdoors?
How often is dog outdoors unsupervised? How long?
How does your dog react to car rides?
Do you ever leave your dog alone in the car?
TRAINING
Has the dog ever attended a puppy socialization class?
Has the dog ever attended a formal obedience training class?
At what age
With which family member(s)?
Success
Select One
Excellent
good
Fair
Poor
What type of collar do you use for training?
Select One
Flat Collar
Head Collar
Choke Chain
Prong Collar
Shock Collar
Please describe the type of training (Strictly positive reinforcement, some positive reinforcement, punishment, etc.)
What will the dog do on command reliably in the home? What will the dog to on command reliably outside the home?
Any ongoing training?
Family member(s) with most control?
Family member(s) with least control?
Describe your dog’s learning ability: (Fast, slow, stubborn, easily distracted, etc.)
CRATE TRAINING
Have you ever used a crate for confinement?
Select One
Yes
No
Do you still use a crate? If so, when?
What type of crate do you use? (Wire kennel, plastic airline kennel, canvas crate, etc.)
Crate location:
Describe the dog’s reaction to being crated:
If you stopped, explain when and why:
PUNISHMENT
Have you used any of the following correction techniques? Other:
What was the success rate of these techniques?
Select One
High
Medium
Low
None
Has any punishment made the problem worse or caused aggression?
Does the pet react differently to punishment from different family members?
AGGRESSION DATA
Does your dog do any of the following? Has your dog ever bitten hard enough to break the skin or cause injury to a person or dog?
Select One
Yes
No
Is your dog aggressive to family members? Please describe in detail:
Is your dog aggressive to non-family members? Please describe in detail:
Do any of the following cause aggression (growl, snarl, lip curl, bark, snap, bite, glare)? Describe circumstances such as approach when eating, chewing toy or bone, disturbed when resting, punishment or discipline, people or animals entering home or yard:
Is there any particular type of handling that leads to aggression? Describe any other situations, not previously discussed where the pet has been aggressive:
Is there a particular person or type of person (baby, children, men, etc.) that the dog is aggressive toward?
Does your dog show fear at the time of aggression? (Growling, snapping, biting accompanied by cowering, ears back, lowered head, neck or body, hackles raised, tail tucked, retreating, hiding) Please describe in detail:
Describe any situations that make your pet shy, fearful or timid:
PRINCIPAL COMPLAINT
Please describe the primary problem and how it developed
What is the severity level?(Mild, moderate, severe, other)
What do you think is the reason for your dog’s problem?
How many times has the problem occurred in the past week?
How many times has the problem occurred in the past month?
How many times has the problem occurred in the past year?
Describe any change in frequency or appearance, and reason why:
What age was your pet when this problem started? Describe in detail the first incident:
Were there changes in the home when the problem first appeared that seemed to affect the dog?
What has been done so far to correct the problem? (Discipline, crate, etc.)
What was the dog’s response?
What techniques have been successful?
What techniques have made the problem worse?
List any training devices tried so far and the dog’s response: Have any drugs been tried? If yes, please list drugs, dosage, dates and effect on the pet:
Additional comments on principal problem:
Are there any specific conditions which seem to trigger the behavior?
Can the dog be interrupted when engaged in the behavior?
How long is the interval between the behavior stopping and the beginning of the next occurrence?
WHAT IS YOUR ULTIMATE GOAL?
For example: Your dog has gotten into 5 fights with other dogs and of those 5 fights, he has sent 5 dog to the vet with bite wounds. Your goal is for your dog to play nicely with other dogs. This is not a “reasonable” goal.:
OTHER ADDITIONAL PROBLEMS
Other
