Reactivity Intake Form Step 1 of 6 16% 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 Medical HistoryInitial medical history questionnaire can be found in the New Client Intake Form. Has your dog ever had a litter of puppies? Yes No At what age was your dog spayed or neutered? Did your dog’s behavior change in anyway after being spayed or neutered? Yes No What behavior changes were there after spay/neuter? List of current medications or supplements:What brand and type of flea preventative? Brand and type of heartworm preventative? What side effects does your dog’s medication have? OverviewDescribe the reason for your consultation today:What do you want to accomplish with this consultation?What about your dog’s behavior concerns you the most?What do you wish to accomplish with training? Behavioral HistoryEarly LifeWhat kind of environment was your dog raised in before 8 weeks old?Where did you get your dog from? How much interaction has the dog had with dogs during the first year of their life? If you got your dog as a puppy, what kinds of places did you take him to before he was 4 months old?If you got your dog as a puppy, what was his reaction to dogs when he was under 4 months old? What pet stores, doggy day cares, vet clinics, groomers, or other pet facilities did you take him to before the age of 6 months old?How old was your dog when you began noticing your dog’s reactions towards other dogs? Did your dog ever have a negative interaction with another dog as a puppy? If so, please describe the situation.Home EnvironmentDoes your dog listen to you inside your home? Yes No Does your dog listen to you in your yard? Yes No What behaviors does your dog know without hesitation while at home? (e.g. sit, stay, lie down, etc.)Which of these does he/she know without hesitation outside the home? Where does your dog stay during the day when no one is at home? How does your dog behave when you’re getting ready to leave the house? Is your dog destructive or a nuisance to neighbors in any way while you’re away? Yes No Does he react and/or bark at dogs while looking out the windows? Yes No Do you play with your dog? Yes No If you play with your dog, what kinds of interactions or games do you play with him? What are your dog’s favorite toys? Who in your family plays with your dog the most? What do you do to reward your dog for good behavior? What do you do to discourage undesirable behavior? List rewards your dog absolutely loves (include food, treats, toys with specific brands, types, etc.):Bite HistoryHas your dog ever made contact and/or bitten another dog? Yes No Has your dog ever made contact and/or bitten a person? Yes No If your answer is yes to either question, please complete the Bite History Questionnaire. Other Dogs While Out & About On a LeashOn LeashDoes your dog pull on the leash? Yes No What tools have you used to try to curb pulling?Martingale CollarProng CollarChoke ChainE-CollarBark CollarCitronella Collar/SpraySpray Water BottleClickerExtendible (Flexi) LeashWaist LeashFront-Attach HarnessNo-Pull HarnessRegular HarnessHead HaltiGentle LeaderOthersOther tools you have used to try to curb pulling: What is your response when you see another dog coming down the street? What is your dog’s response when he spots another dog 100+ yards away? What is your dog’s response when he spots another dog 50-100 yards away? What is your dog’s response when he spots another dog 20-50 yards away? What is your dog’s response when he spots another dog less than 20 yards away? Distance that your dog does not react? Types of dogs that bother him most? (Size? Breed? Color? Age?) Has he ever met another dog on leash? If so, what happened?Has he ever met another dog off leash? If so, what happened? Other PeopleWhat is the dog’s reaction to visitors in your home?Describe your dog’s reaction to children visiting:Describe your dog’s reaction to adult women visiting:Describe your dog’s reaction to adult men visiting:Does your dog react to accessories such as canes, large coats, or hats? If so, what accessories?What is the dog’s reaction to adults while out and about on a leash?Your dog’s reaction to children while out and about on a leash?What is the dog’s reaction to adults or children while off leash in an enclosed area outside of your home/yard?Has your dog had any negative experiences with people in the past? If so, please describe: Other QuirksDoes your dog have any odd or unusual behaviors inside the home? Does your dog have any odd or unusual behaviors in your yard? Does your dog have any odd or unusual behaviors outside your home or yard? Other quirks your dog has: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.
