BEHAVIOR ASSESSMENT INTAKE FORM Your Name: Date: Address: Phone # City: Zip: Who referred you to us? DOG INFORMATION Dog of concern; Name, Breed, Sex, Weight and Age: How long have you owned or fostered this dog(s)? List any other dogs in the House (Provide Dog s Name, Breed, Sex, Weight and Age): List any other relevant pets (cats, birds, etc.): List any known medical conditions, physical injuries, or current limitations for the primary dog(s): List any medications that the primary dog(s) currently take: Are rabies vaccinations current? Y N Are the dogs Neutered/Spayed? Y N Where does your dog sleep at night? Does your dog whine or bark while in their crate? Y N How long do you crate the dog during daylight hours? hrs. What kind of exercise does your dog get and how often? BEHAVIOR PROBLEMS
Does your dog... YES NO N/A 1. have issues with urinating indoors?... 2. urinate from excitement or submission?... 3. chew things they shouldn t like clothing or furniture?... 4. steal items such as towels, shoes, food from countertop etc.?... 5. run away, hide, or become possessive while holding material items?... 6. get excited/jealous when you give attention to another dog/person?... 7. growl, lunge, or bark while eating from a bowl?... 8. growl, lunge, or bark with bones, chewies, or rawhides?... 9. growl, lunge, or bark with toys or similar items?... 10. bark or chase people or animals behind your fence?... 11. become grumpy when started or awaken from sleep?... 12. follow you or anyone in the house from room to room... 13. constantly beg for attention?... 14. bark or whine when left alone?... 15. have any problems going into their crate?... 16. have difficulty dropping items, coming when called, etc.?... 17. randomly lay on your feet, step on you, or sit on you... 18. lean its shoulder, body, rear-end, or tail against your lower leg?... 19. nap or seek shelter under or behind tables, chairs, or sofas?... 20. dislike being touched in the paws, ears, face, back legs, etc.?... 21. have any issues putting a leash or collar on?... 22. bite or use its mouth on humans when challenged?... 23. jump up on you or on guests?... 24. get mouthy with people when excited, bored, or playing?... 25. pee multiple times during a walk (marking)?... 26. constantly pull on a leash?... 27. walk between your legs, weave, or walk side-to-side on a leash?... 28. kick up grass/dirt after pooping or peeing?... 29. react poorly to other dogs or distractions on leashed walks?... 30. is your dog tense, nervous, skittish, anxious, or fearful?...
31. whine before leaving the house to travel or go for a walk... 32. uncontrollably chase or stare at shadows, lights, or reflections... WHEN WAS THE LAST TIME YOUR DOG 33. met a new person? 34. met a new dog? 35. walked on a leash outside of your home? 36. has been to the veterinarian's office? 37. bit a human or another dog? 38. endured a drastic environmental change such as moving homes, human or dog companion passing away, etc.? 39. endured a traumatic event such as physical abuse, hit by car, abandoned, etc.? Significant Behavioral Tendencies For the following questions, please indicate whether or not your dog currently has, or has had, any significant behavioral tendencies with the following types of people and animals. Significant here would include incessant barking, growling, tensing up, snapping, charging/lunging, snarling, hard stares, biting, killing, or fleeing/hiding from the types of people / animals listed below. 40. Children / toddlers / babies... 41. Family members / roommates... 42. Primary owner(s)... 43. Friends or guests in the home... 44. Friends or strangers off-property... 45. Other dogs in the home... 46. Other non-resident dogs or dogs off-property.. 47. Other animals (cats, birds, rabbits, etc.)... YES NO N/A DETAILS If you answered yes to any of the questions above, please take the time to give a detailed explanation of the incident(s) below. If the dog has bitten a person or another animal, please include all relevant information. You can also include behavioral issues which your dog exhibits that are not on the list.
Be sure to describe the behaviors in detail, including when the behavior first started/appeared, the circumstances of the incident(s), and the severity / intensity of the issue. Also include what steps have been taken so far to address, resolve, or manage each of the problem behaviors. If your dog was adopted or rescues, please include any pertinent information such as abuse, neglect, or trauma. When providing details about your dog s behavior issues below, please remember to include the question # with your description. Please do so for each Yes response. For example: 3. Rocky chews on my shoes when I am at work. This started 4 months ago after my daughter went off to college. We have tried locking him in the bathroom but that has not worked. 7. Rocky growls when I try to take his bones.