Bite History Questionnaire Step 1 of 4 25% Client InformationToday’s Date* MM slash DD slash YYYY Client's Name* First Last Home/Cell Phone*Email* Dog InformationDog's Name:* Date of Birth* MM slash DD slash YYYY Breed or Breed Mix* Weight* Sex:* Female Male Spay/Neuter* Yes No OverviewHow many times has your dog bitten a person?* 0 1 2 How many times has your dog bitten another dog?* 0 1 2 3 or more Have you received a court order to hire a dog trainer to evaluate or train your dog? Yes No MedicalWas your dog on any medications at the time of the bite? Yes No Had your dog recently experienced a surgery or infection at the time of the bite? Yes No Did your dog receive any wounds from another animal at the time of the incident? Yes No Bite History on Dogs or Other AnimalsWhat age was your dog when he/she first bit another animal? Is your dog protective over his food with other animals? Yes No Is your dog protective over his toys with other animals? Yes No Describe the situation that occurred that caused the 1st bite:Please describe the 1st bite to another animal: (e.g. puncture, tear, bruising, etc.)Had your dog recently experienced a stressful event at the time of the 1st bite? If so, what?How serious was the 1st bite?Did the bite require a veterinary visit? Yes No Was there a surgery or stitches required? Yes No Describe the situation that occurred that caused the 2nd bite:Please describe the 2nd bite to another animal: (e.g. puncture, tear, bruising, etc.)Had your dog recently experienced a stressful event at the time of the 2nd bite? If so, what?How serious was the 2nd bite?Did the 2nd bite require a veterinary visit? Yes No Describe the situation that occurred that caused the 3rd bite:Please describe the 3rd bite to another animal: (e.g. puncture, tear, bruising, etc.)Had your dog recently experienced a stressful event at the time of the 3rd bite? If so, what?How serious was the 3rd bite?Did the 3rd bite require a veterinary visit? Yes No Was there a surgery or stitches required after the 3rd bite? Yes No Bite History of PeopleIs your dog protective over certain areas of his body? If so, which parts?Does your dog let you groom him/her? What areas of his body is he uncomfortable with you touching?Is your dog protective over food with people? Yes No Is your dog protective over toys with people? Yes No Describe the situation that occurred that caused the 1st bite to a human:Please describe the bite: (e.g. puncture, tear, bruising, etc.)Had your dog recently experienced a stressful event at the time of the bite? If so, what?How serious was the bite?Did the bite require a hospital or doctors visit?Describe the situation that occurred that caused the 2nd bite to a human:Please describe the 2nd bite: (e.g. puncture, tear, bruising, etc.)Had your dog recently experienced a stressful event at the time of the 2nd bite? If so, what?How serious was the 2nd bite?Did the bite require a hospital or doctors visit for the 2nd bite?Was there a surgery or stitches required for the 2nd bite? Follow Up QuestionsDescribe situations that make your dog nervous or uneasy:Have you ever considered rehoming your dog? If so, why?Have you ever considered euthanasia? If so, why?Thank you for taking the time to fill out our registration form. These details will help us better serve you and your dog. We look forward to working with you! Please verify the information was entered by you. Thank you.I understand and agree to the policies at the bottom of this page.* Yes No Signature*By indicating my consent, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this Agreement. If I am signing on behalf of another individual, I attest that I have the authority to do so.To submit your information, please hit send. If you do not receive confirmation the form has been sent, scroll up to make sure all required fields have been entered. Policies Paid pre-registration is required to reserve a space in class. There will be no refunds after class begins. Please make sure your dog’s vaccinations are up-to-date. Only healthy dogs may come to in-person classes and training. Owners should keep their dogs at home or reschedule private training in cases of sneezing, coughing, diarrhea or other potentially contagious symptoms. Owners are expected to maintain and reinforce training outside of the class setting. Children 8 and over are welcome at in-person group classes as long as they remain with their parents throughout class, and follow trainers’ instructions. At their discretion, instructors associated with Joyful Dog LLC have a right to refuse admission to or expel a dog/handler from class. Waiver I understand that attendance at a dog training class is not without risk to myself, my dog, members of my family or guests who may attend. I agree to release and hold Joyful Dog LLC, its instructors and teaching assistants, the training facility, and their respective officers, directors and employees harmless of any liability arising from this training activity and/or information or consultation provided by Joyful Dog LLC. I expressly assume the risk of damage or injury therefrom.
