GREAT COMPANIONS Pre-Consultation Behavior History Form

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GREAT COMPANIONS Pre-Consultation Behavior History Form In order to effectively assist you with your dog, it's important that I obtain as much information as I can about your dog's history. Please complete this questionnaire as accurately as you can. Upon completion print it out, then save a copy where you can find it on your computer. Then you may send it to Great Companions, P.O. Box 36, Neffs, PA 18065, along with your check for $375 to Great Companions. Or submit via email (click above) and make payment using PayPal on the Class Schedule page. Once I receive the form and payment, I will call you to schedule your first appointment. Thank you for your time and consideration, and I look forward to working with you. Ali Brown, M.Ed., CPDT 610 737-1550 Save your form and attach it to this email Name: Street Address: City/State: Zip Home Phone: Work/Cell Phone: Email: Housing: apartment/condominium duplex single family home Fenced Yard: Yes No Dog s Name: Breed or Mix: Date of birth (if known) Sex: female male spayed/neutered Obtained from: breeder adopted/rehomed from shelter or rescue group Other: Age of dog when acquired: Number of previous owners: Food: Commercial Dry Commercial Canned Raw Prescription Home Cooked Brand: Frequency of meals: once a day 2+ times a day free fed Food allergies: Medical conditions (past or present): Exercise: times/day for minutes times/week for minutes Type of Exercise: walk run/jog interactive play dog park dog daycare Number of hours dog is alone each day: When alone: Dog is crated/kenneled confined in one or more rooms free access to entire house gets a break

List name/ages of all other humans living in household: List other pets/animals living in household: Dog s Formal Training: Puppy class age: Trainer/school Basic adult age: Trainer/school: Intermediate/CGC age: Trainer/school: Sports (agility, flyball) age: Trainer/school: Competition level age: Trainer/school: Training equipment: flat buckle collar harness (standard) slip/choke collar martingale prong collar E-collar (shock) harness (no pull) anti-bark (shock) head halter (Gentle Leader, Halti) anti-bark (citronella) Has your dog ever bitten anyone under any circumstances? Yes No If yes, how many incidents Severity of bites Nip/No visible marks Minor Scratch/Abrasion Teeth Marks Puncture (No Medical Attention) Puncture (Requiring Medical Attention) Describe the most severe bite incident:

Reason(s) for consult: On a scale of 1-10 (1 being a slight nuisance to 10 being considering giving up/ euthanizing dog), how would you rate the severity of this issue? When did onset of problem occur? days weeks months years ago. Has problem increased in frequency or severity? Yes No Please describe in detail the last two incidents involving or prompted by this issue: 1. 2.

Please list any/all additional concerns: How have you handled this issue in the past: Have you consulted with or sought out the help of others for this issue? If so, please list name/contact info. Trainer(s): Behaviorist(s): Veterinarian(s): Please list any/all recommendations you were provided:

Please list any/all methods of discipline/punishment you have used: verbal reprimand leash corrections timeouts ignore behavior hit with hand hit with object scruff pin down/alpha roll other (describe) Please rate how often your dog exhibits the following behaviors. 1-Never 2-Rarely 3-Sometimes 4-Often 5-Always Barks and/or lunges at people on leash at unfamiliar dogs Barks and/or lunges at people off leash at unfamiliar dogs Initiates fights with male dogs with female dogs Has bitten an unfamiliar dog dog within same household Growls at people Growls at unfamiliar dogs Mounts other dogs Tries to mount humans legs Crouches/submissive to other dogs to humans Ignores other dogs Runs/Hides from other dogs Runs/Hides from strangers Urinates when approached by strangers Sits when asked Lies down when asked Stays in place when asked Comes when called in confined area Comes when off-leash in public area Jumps up on people when greeting Jumps up on counters Guards (growls/snaps) food/toys from other dogs Guards food/toys from humans Growls/snaps during grooming Growls/snaps when attempting to move from bed/sofa Growls/snaps at children Growls/snaps at men or people in uniform Fearful of loud noises (fireworks, thunder, trucks) Fearful of new places Barks/whines/howls when crated/kenneled Barks/whines/howls when left alone Destructive to property when left alone Attempts to get out of crate/room

Injures himself when left alone Will not eat when left alone Urinates/defecates in house when left alone Urinates/defecates in crate Licks self excessively Licks you (humans) excessively Barks/lunges at moving objects (bicycles, skateboards, joggers) Chases cars Barks/howls at night Barks at passersby through window Eats inedible items (rocks, plastic, glass, coins, socks, underwear) Eats his own (or other dog s) feces Please list any specific questions you would like answered during the consultation: Please list your expectations for this consultation: Please list your expectations/goals for your dog: Vaccine Check: (for trainer use only):

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