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OWNER INFORMATIONYour Name: __________________________________________

Phone: _____________________ Cell: ___________________

Address: ____________________________________________

Email: ______________________________________________

PET INFORMATIONPet’s Name: ___________________________________________

Current Age/Birthday: __________________________________

Breed: _______________________ Color: __________________

Male Female Intact Neutered/Spayed

Vet: _________________________________________________ Vet Number: __________________________________________

Where did you obtain your dog (breeder, shelter, found)? _____________________________________________________________

When did you acquire your dog? Month _______________________ Year _______________

How old was your dog when he/she was acquired? __________________________________

List all other dogs in the household.

Breed: ________________________________ Age: _______ Male Female Neutered/Spayed DATE ACQUIRED: __________

Breed: ________________________________ Age: _______ Male Female Neutered/Spayed DATE ACQUIRED: __________

Breed: ________________________________ Age: _______ Male Female Neutered/Spayed DATE ACQUIRED: __________

Describe the dynamics between the dogs. Who do you perceive is the alpha? Who is the submissive dog?

____________________________________________________________________________________________________________

Your home consists of: Partner/Spouse Roommate

Children - GIVE AGES: _____________________________________________

Is there anyone in the household that the dog has issues with? ________________________________________________________

Does the dog have a favorite family member? ______________________________________________________________________

Who in the family does the dog show the most respect? ______________________________________________________________

What brand/kind of food does your dog eat? __________________________________ Who feeds the dog? ___________________

Yes Picky Normal Voracious

____________________________________________________________________________________________________________

How much exercise does your dog get?

Daily Walk Walk 1-3 Times/Week Couch Potato Other __________________________________________________

EVALUATION DATE: __________________ TRAINER INITIALS: ________

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What is your dog’s training history? (Check all that apply) Very Basic Puppy Kindergarten Group Classes Trained Yourself Titles: _________________________________ Private Training (if so, who?): ________________________________________Dog’s favorite game: _______________________________ Favorite Toy: _______________________________________________

Yes NoIf yes, please describe: _________________________________________________________________________________________

Is your dog possessive of toys, food, or objects? Yes NoIf yes, please describe: _________________________________________________________________________________________

Does your dog show fear toward any of the following? (Check all that apply)Men Women Children Moving Objects (bicycles, vacuum cleaners, cars) Loud Noises Thunder Other, please describe: _______________________________________________________________________________________

Does your dog have issues with any of the following? (Check all that apply) Nails Trimmed Cleaning Ears Baths Rubbing Belly Rolling Over Grasping Collar

Has your dog ever: Growled at you, or Tried to bite you or a family member? If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has your dog ever: Growled at, or Tried to bite a stranger If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has your dog ever: Growled at, or Tried to bite another dog If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does your dog have any of the following issues? Check any that apply:

Have you ever used a crate for confinement? Yes Yes No

Was/is the crate: Wire Other: _______________________________________________________________________

How did you hear about The Dog Knowledge? ______________________________________________________________________

What is the main reason that you have chosen The Dog Knowledge for your pet? Training Boarding Daycare Group Classes Agility Other _____________________________________________________________________________________

Are there other issues that you wish to address or feel you should inform us of? Yes No

Owner Signature _________________________________________________________ Date: ______________________________

Urine MarkingCounter SurfingUrinates when afraidTimid/ShyHowlingEats other dog’s stool

Chews/Licks SelfJumping on PeopleWhining

Trash Can RaidingLicks PeoplePushy

Tail ChasingUrinates when ExcitedSleep DisordersBarkingEats own Stools

Have you or someone else ever used a shock collar on your dog? Yes No

The Dog Knowledge • 704.365.1892 • 704.365.1894 fax • 1110 ProAm Drive • Charlotte, NC 28211 • Located off Wendover Road

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Supplemental CanineBehavior Questionnaire

OWNER NAME: _________________________ PET NAME: ____________________________

Describe the primary problem:

__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

How much of a problem do you consider the behavior to be? Very Serious Serious Not Serious

Describe the problem beginning with the most recent incident:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

Describe previous incidents:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

Describe the first incident:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

What age was your dog when the problem started? _______ How often does the problem occur? __________________

Has there been a recent change in frequency or severity? Yes No If yes, explain:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

Describe any changes in the home when the problem first appeared: __________________________________________________________________________________________________

Have you actually seen the problem? Yes No If yes, what did you do?

__________________________________________________________________________________________________ __________________________________________________________________________________________________

What has been done so far to try to correct the problem?

__________________________________________________________________________________________________ __________________________________________________________________________________________________

The Dog Knowledge • 704.365.1892 • 704.365.1894 fax • 1110 ProAm Drive • Charlotte, NC 28211 • Located off Wendover Road

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What was the dog’s response?

__________________________________________________________________________________________________ __________________________________________________________________________________________________

List any techniques that have had success:

__________________________________________________________________________________________________

List any techniques that, in your opinion, have made the problem worse:

__________________________________________________________________________________________________

Describe the first incident:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

List any medications tried, and the dog’s response:

_________________________________________________________________________________________________

What do you think is the reason for your dog’s problem?

__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Have you considered rehoming your dog? Yes No Maybe

Have you considered giving your dog up to a shelter? Yes No Maybe

Have you considered euthenasia? Yes No Maybe

Additional comments:

__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________