Phone
Email *
Pet's Name: *
Breed
Date of Birth or Age *
Where did you get your dog? *
How long have you had your dog? *
If so, how many other owners? *
If applicable, please explain why your dog was relinquished by the previous owners. *
How many people in the household?
What are your goals for this appointment?
If you feel that the relationship of the patient with a particular person is important to the assessment and treatment of the problem for which you are bringing your dog, please describe.
How many play sessions does your dog get per day?
List the other animals in the household and describe their relationship with the patient. *
Please describe any significant medical illnesses, treatments and the outcome.
What do you feed your pet? *
Does your pet have any allergies or food sensitivities? *
List the first concern for which you are see seeking help *
Age at which problem 1 started:
Frequency of problem 1
List the second concern for which you are see seeking help *
Age at which problem 2 started:
Frequency of problem 2
List the third concern for which you are see seeking help *
Age at which problem 3 started:
Frequency of problem 3
If you have worked with a dog trainer previously, please list the company and trainer name and what behaviors were taught. Include puppy classes. This helps us to know what behaviors and methods have been used thus far in training your dog.
Number of bites?
Number of bites that broke the skin?
Number of bites that were reported to public health authorities?
Number of bites?
Number of bites that broke the skin?
Number of bites that were reported to public health authorities?
If you chose Other, please explain:
If you chose Other, please explain:
If you chose Other, please explain:
If you chose Other, please explain:
If you chose Other, please explain:
Please add any additional information that you would like to share about how, when or to whom your pet is aggressive.
If you chose Other, please explain:
If you chose Other, please explain:
If you chose Other, please explain:
Please add any additional information that you would like to share about your dog's reaction to scary sounds.
If you chose Other, please explain:
If you chose Other, please explain:
If you chose Other, please explain:
If you chose Other, please explain:
Please add any additional information that you would like to share about your dog's anxiety or panic when you leave.
Please add any additional information that you would like to share about your dog's behavior in the car.
Please add any additional information that you would like to share about the behaviors listed above
Anything else that you would like to share with us about your pet?