Canine Behavioral History Form Step 1 of 5 20% Please answer the following questions and email this form back to us 48 hours before your appointment. *denotes a required field YOUR DOGName:* Sex:* Male Female Neutered?* Yes No Breed* Age*Please enter a number from 0 to 30.Weight* How long has s/he been a part of your household? Where did you get him or her from?* Breeder Rescue Shelter / Humane Society Pet store Stray YOUR CONTACT INFOName* 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 Phone*Email* Best Way to Be in Touch* Email Phone How did you hear about Joyful Dog LLC? YOUR HOUSEHOLDHow much exercise does your dog get each day, and what form does this take? Are weekdays different from weekends? How does your dog spend his/her days? (For example: Inside or outside? Crated? For how long?)Is this your first dog? Yes No Please list the people who interact with or care for your dog.Are there any other animals in the house? If so, list name, species, breed, sex and neutered status, and age. PROBLEM BEHAVIORDescribe the problem behavior, or reason you are seeking a consultation.When did this behavior start?Did anything else change in your dog’s life around the time you became aware of the behavior? (For example: Did you move? Did anyone join or leave the household? Were there any changes in daily routine?)How frequently does your dog engage in this behavior?Have you tried to manage, alter, or change this behavior? If so, what methods or tools have you used?Is the behavior getting better or worse? Please explain. BITE HISTORYHas your dog ever lunged and snapped at a person? (Man, woman, or child) Yes No Don't know Has your dog ever bitten a person? (Man, woman, or child) Yes No Don't know If yes to either of the two preceding questions, please give additional details. (For example: what happened just prior to the bite? How badly was the victim injured?)Has your dog ever lunged and snapped at another dog or pet? Yes No Don't know Has your dog ever bitten another dog or pet? Yes No Don't know If yes to either of the two preceding questions, please give additional details. (For example: what happened just prior to the bite? How badly was the victim injured?)If your dog has bitten or threatened to bite, please rate the most severe incident: Level 1: Obnoxious or aggressive behavior but no skin-contact by teeth (lunges but no contact made) Level 2: Skin-contact by teeth but no skin-puncture. There may be skin nicks (less than one tenth of an inch deep) and slight bleeding caused by scraping of teeth against skin, but no vertical punctures Level 3: One to four shallow punctures from a single bite (dog bit and quickly released) Level 4: One to four punctures the full depth of the teeth with bruising around the punctures (dog bit and shook his/her head before releasing) Level 5: Multiple-bite incident with rending and tearing Level 6: Bite killed victim None of the above TRAININGType of training you and your dog have participated in: In-home private consultations Group classes Puppy classes Puppy play group Agility, Rally, or other sport Have you ever used aversive or correction-based training with this dog? (For example: Yelling; hitting; choke, prong, or electronic collars; “alpha rolls”; etc.) Yes No Don't know Are you willing to use positive, reward-based methods to address the problem behavior? (We use only positive rewarding, methods at Joyful Dog LLC.) Yes No Don't know MedicalPlease tell us about any medical conditions you are aware of.Does your dog have any allergies to food or the environment?Does your dog take any medications, pills, supplements, or prescriptions? If so, what and how often?VeterinarianName First Last Veterinarian's nameAddress Street Address City ZIP Code Veterinarian's addressPhoneVeterinarian's phone numberDate of last visit (approximate): Please verify the information was entered by you. Thank you.
