BEHAVIOURAL CONSULTATION FACT SHEET
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Date
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Month
-
Day
Year
Date
Name of Owner or Caregiver
*
First Name
Last Name
Name of Dog
*
Email Address
*
example@example.com
Behavioural Concerns
What do you wish to accomplish?
Did this problem develop recently?
Is there a specific reason/event that you know of that precipitated this behaviour?
DOG’S INFORMATION
WHERE WAS DOG OBTAINED?
TELL US ABOUT YOUR DOG
Please list any and all family members including yourself, and their ages who are living in the home, either full- or part-time. Please indicate their relationship to the human family and their relationship with the dog (e.g. good/afraid/doesn’t like dogs/likes but too harsh when he misbehaves, etc.)
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PLEASE DESCRIBE THE PERSONALITY OF THE PEOPLE LISTED ABOVE: (e.g.calm, anxious, gets stressed easily, easygoing, quick tempered etc) **You may choose not to answer if you desire, and any information is fully confidential. The only purpose is to give the consultant more insight as to how to best enable your family and your dog to succeed.**
Please list any other animals in the household in the order in which they were obtained, starting with the one who has been in the home the longest.
HAVE ANY OF THE FOLLOWING CHANGES OCCURRED IN THE LAST 18 MONTHS?
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WHAT IS THE NAME OF YOUR VET CLINIC?
NUTRITION
MEDICAL
OUTSIDE ACTIVITY Is this pet (please fill all that apply to your dog)?
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PREVIOUS TRAINING
What commands does your dog know and how well:
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DOMINANCE
TRAINING AND EQUIPMENT USED
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INTERACTIVE BEHAVIOUR
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Please check the appropriate box if your dog exhibits any of the listed behaviours at any time when you or any member of the family do the following:
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SLEEPING ARRANGEMENTS Where does your pet sleep at night (in a crate, on your bed, in the hallway, not allowed upstairs etc.)?
DAY TIME HOURS
CRATE TRAINING
HOUSETRAINING (ONLY FILL OUT THIS SECTION IF YOU HAVE HOUSETRAINING CONCERNS)
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BEHAVIOUR
DOES YOUR DOG REACT IN AN INAPPROPRIATE MANNER TOWARDS ANY OF THE FOLLOWING? IF YES, PLEASE EXPLAIN.
SEPARATION ANXIETY (ONLY FILL THIS OUT IF THIS IS A BEHAVIOR CONCERN)
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SUMMARY
FINALLY, IF WE HAVE MISSED ANY DETAILS OR PROBLEMS, PLEASE USE THIS SPACE TO TELL US ABOUT THEM
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