Behavioral Questionnaire

Client Information

The * means that it is a required field. Please provide as much information as possible.

Client's First Name*

Client's Last Name*

Address Line 1*

City*

State*

Zip Code*

Email*

Primary Phone

Secondary Phone

Dog's Name

Dog's Breed

Dog's Age

Is Your Dog Spayed or Neutered?

Yes
No

Dog's Gender

Male
Female

Who is your regular veterinarian?

Behavioral Information:

Please provide as much information as possible. This information will provide a preliminary understanding of your concerns and make our appointment more productive.

1) List the behaviors of concern. Prioritize them (which are most important to address).

2) Starting with the behavior on the top of your list, the one that concerns you the most, when did you first notice the behavior (age of dog)?

3) Is it increasing in frequency?*

Yes
No

4) How often does the behavior occur? Does it happen every day and/or how many times a day?

5) Does the behavior happen any particular time of the day?

6) What do you think stimulates or motivates the behavior? Is it associated with anything you or a family member does?

7) What have you done to try to change or stop the behavior? Or how do you correct the dog?

8) Please list two recent examples of the behavior. Explain what happened, how you handled the dog, and the outcome.

9) Why do you think the dog is behaving in this manner?

10) Please describe the 2nd behavior from your list in detail. What is the behavior, when does it happen, and what have you done to try to work on it or correct it?

11) Please describe the 3rd behavior from your list in detail. What is the behavior, when does it happen, and what have you done to try to work on it or correct it?

12) Have you owned a dog before?*

Yes
No

13) Where did you get this dog?*

13 a) If from a breeder, please list breeder name and location.

14) If known, describe your dog's behavior as a puppy (e.g., very mouthy, timid around people, very confident).

15) If you adopted your dog, describe how your dog behaved during the first 3 weeks in your home.

16) Please list the people living in your home. Please include name, ages of children and describe your dogs response to each person.

17) Please list the other animals in your home (in the order in which they were obtained). Please include name, species, breed, sex, age obtained, age now.

18) What is your dog's relationship with the other animals (e.g., friendly, hostile, fearful)? Please describe.

19) What do you feed your dog and how many times a day?

20) Does your dog have a good appetite?

21) Who feeds your dog? And where?

22) What is your dog's favorite treat?

23) Please describe a typical 24-hour day in your dog's life (include how many walks and romps in the yard).

24) Is your dog in a:*

fenced in yard
electric fenced in area
tether run
kennel run
boundary trained, no fence
walked on leash

25) What is your dog's outdoor experience?*

left outside all day on its own
left outside for long periods of time
let out just to potty
you go out with your dog to potty and play

26) How do you play with your dog (e.g., fetch, tug, chase)? And, how often?

27) Does your dog have a favorite type of toy? If so, what is it?

28) Does the dog give up the toy when asked?*

Yes
No

29) Did you train "drop it"?*

Yes
No

30) How does your dog walk on a leash?

31) How many walks do you take your dog on in a day?

32) What do you give your dog to chew on or keep busy with (bones, kongs, treat balls)?

33) Where does your dog sleep at night (please be specific)?

34) If your dog sleeps in the bed, does s/he growl or snap if you move at night?

35) Where does your dog stay when alone in the house (please be specific)?

36) How does your dog behave while you are leaving the house?

37) How does your dog behave when you return?

38) How does your dog behave when someone familiar enters the house?

39) How does your dog behave when someone unfamiliar enters the house?

40) Does your dog act differently towards men or children?

41) Does your dog seek attention by:

none. Dog doesn't elicit any attention seeking behaviors.
barking
stealing
mouthing
mounting
Other

41 a) If other, please explain.

42) Does your dog eliminate in the house?*

Yes
No

42 a) If yes:

Urinate
Defecate

42 b) If your dog eliminates in the house, does it happen when:

you're home
you're out

43) Do you use a crate?*

Yes
No

44) Have you done training? If yes, please describe (for example: private training, group classes, trained on your own).

45) Did you complete and follow through with the training?

46) What style of training did you use?

None
Positive
Collar correction
Other

46 a) If "other", please describe.

47) Who did you train with (trainer name and location)?

Aggression Screen 1: Please click a response for every item below.*

Aggression Screen 2: Please click a response for every item below.*

Aggression Screen 3: Please click a response for every item below.*

Aggression Screen 4: Please click a response for every item below.*

Aggression Screen 5: Please click a response for every item below.*

	Bark	Growl	Snarl/bare teeth	Snap/bite	No Reaction	Not Sure
Verbally punish dog
Physically punish dog
Speak to dog (normal tone)
Stare at dog
Bend over dog
Push on shoulders or back
Approach dog near spouse or family member

Aggression Screen 6: Please click a response for every item below.*

Aggression Screen 7: Please click a response for every item below.*

Aggression Screen 8: Please click a response for every item below.*

Aggression Screen 9: Please click a response for every item below.*

	Bark	Growl	Snarl/bare teeth	Snap/bite	No Reaction	Not Sure
Unfamiliar adult enters house or yard
Unfamiliar child enters house or yard
Familiar adult enters house or yard
Familiar child enters house or yard
Response to toddlers/babies
Dog in car at tollbooths, gas stations

Aggression Screen 10: Please click a response for every item below.*

	Bark	Growl	Snarl/bare teeth	Snap/bite	No Reaction	Not Sure
Unfamilar adult approaches owner, dog on leash
Unfamiliar child approaches owner, dog on leash
Dog in house, sees people outside
Response to other dogs while on leash
Response to other dogs while not leashed
Response to other dogs who are not leashed

If you clicked on any aggressive responses, please continue with this part of the questionnaire.

AG-1) What was the age of your dog when you first noticed the aggressive behavior (growling, snarling, etc.)?

AG-2) What did you do when your dog first started to growl at you?

AG-3) Who is/are the target(s) of aggression?

AG-4) Have there been any bites? If yes, how many bites?

AG-5) How many have broken the skin (if any)?

AG-6) What parts of the body has the dog bitten?

AG-7) Please describe the two most recent episodes including all of the details: who; did the dog growl, lunge, or bite; what were the circumstances; how did you handle it?

End of the aggression section.

Are there any additional comments you would like to make?

End of questionnaire.

Terms and Conditions:

I, the Client, agree to fully cooperate in completing the training sessions as taught by Hudson Valley Dog Training, LLC dba Canine Coaching staff. I will practice the homework assignments to develop the proficiency in the tasks being taught. I understand that every dog reacts in a different manner to training and that dogs are, by nature, unpredictable. Therefore, dog training requires full attention and total awareness at all times. Animals may, without warning, cause injury to humans and/or other animals. I understand and agree that Hudson Valley Dog Training, LLC dba Canine Coaching is not responsible for the behavior of the pet at any time, now or in the future. I, the undersigned, as RELEASOR, in consideration of Hudson Valley Dog Training, LLC dba Canine Coaching, as RELEASEE, release RELEASEE’s heirs, executors, administrators, successors, employees, agents, directors, officers as to attacks, bites, mauling, or all of them, by dogs or other animals to any person or animal including my own for the safety of myself, my dog, those around me and those dogs around me while learning dog training and while working with my dog. I sign below in recognition of my understanding that any injuries received by me, others and/or by my dog or other animals while taking classes, participating in behavior consultations, or after such activities in my home or at any other location are my own responsibility. I further affirm that I will always inform my instructor and Hudson Valley Dog Training, LLC dba Canine Coaching, in writing, of any unusual difficulties or conditions my dog may be experiencing prior to the beginning of a training session or behavior consultation, or during such sessions. This release may not be changed orally. For Behavior Consultations, Hudson Valley Dog Training, LLC dba Canine Coaching agrees to obtain a history of the pet, information about the pet’s living environment and family members, to assess the situation and develop a behavior modification plan, “The Plan”, to attempt to modify the behavior of the animal to the client’s satisfaction. Client agrees to divulge all relevant information to Hudson Valley Dog Training, LLC dba Canine Coaching and to follow the instructions developed by Hudson Valley Dog Training, LLC dba Canine Coaching in the Plan completely and in a timely manner. Client further understands that if the pet lives or comes in contact with other family members, that these individuals may be required to participate in The Plan if it is to produce favorable results. Client also understands and agrees that Hudson Valley Dog Training, LLC dba Canine Coaching is not responsible for the behavior of the pet at any time, now or in the future. No refunds will be made due to client inability to complete full lesson package. Forty-eight hours notice is required for cancellation of enrollment in class. I understand that the instructor reserves the right to expel any person or dog (without refund) whose presence jeopardizes the safety of others.

By checking this box I agree to the Terms and Conditions stated above*

Agree

Would you like to receive emails from our site in the future?*

Yes
No

All required fields must be filled in prior to submission. If the forms stays after submission with this error message: "There was a problem with your submission. Errors have been highlighted below." You must go back to the fields that are highlighted in red and answer the question. If it is submitted successfully, you will be brought to a new page that just says: "Thanks for contacting us! We will get in touch with you shortly."

Name

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	Bark	Growl	Snarl/bare teeth	Snap/bite	No Reaction	Not Sure
Enter room
Leave room
Reach toward dog
Restrain with a leash
Grab the collar
Scruff Restraint
Put leash on/take off
Put collar on/take off

845-634-4344 or 845-517-0517