Intake Form – 1 Dog

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Client Information





Fax (optional)

Patient Info (Dog Info)

Dog Name






Date of Birth

Medical Information

Animal Hospital


Veterinarian Address

Veterinarian Phone

Referred By

Canine Medical History

Is your dog spayed/neutered?

If yes, at what age was the procedure performed, reason for procedure, and finally any behavioral changes after procedure?

Date of Last Rabies Vaccine

Date of Last Lyme Vaccine

Date of last Canine Distemper Vaccine

Date of Last Leptospirosis Vaccine

Please check all current medications

If Yes, Please List Antibiotic Medication or other medication:

List conditions for which your dog has been treated, medication prescribed, and approximate dates:

Has there been any change in your dogs stool?

Does your dog urinate excessively? If so when did he/she start urinating more?

Has your dogs temperament or personality changed? If so when did this occur and describe the change:

Does your dog pace back and forth?

Does your dog stare at objects for long periods of time?

Has the quality of your dogs coat changed?

Is your dog scratching or biting him/herself?

Has there been any changes to his/her sleeping pattern or location?

Chief complaint

What is your biggest problem?

Background Information

Date (approximate) you acquired your dog

Dogs age at that time

Where did you get your dog

Are you their first owner? If no, how many previous owners? Do you know why the dog was given up?

Which traits best describe your dog as a puppy?

What reason did you adopt this dog?

Have you owned pets before?

How did you select this dog over the other selections?

Describe the temperament of the dogs mother: (If known)

Describe the temperament of the dogs father: (If known)

Do you know the status of your dogs littermates?

Describe your dogs relationship to other animals within the household


Please describe a typical 24 hour day in the life of your dog: Typically

Typically what percentage of the day does your dog spend indoors?

Do you have a fenced yard?

Does your dog run unsupervised outdoors?

Where does your dog sleep at night?

Where is your dogs favorite resting spot when you are at home?

Does your dog rest on your furniture?

Describe your dogs favorite toys

Describe any interactive games that you play with your dog and note frequency

Does your dog usually follow you from room to room?

Does your dog have free access to the house when your not at home? If no describe the confinement

How does your dog behave when you prepare to leave home?

How does your dog behave when you return home?

List any items your dog chews or scratches

What specific brand and type of food do you feed your dog?

How long have you been feeding your dog this diet?

Number of meals per day?

Do you leave food down for him/her to eat during the day (graze eating)?

Does your dog allow you to interrupt his eating?

Can anyone take the dogs food away?

Can anyone take away bone/treat?

Can anyone take away toys?

Which family members are responsible for feeding?

Location of bowl(s):

When does your dog eat

Dogs favorite treats

Describe your dogs reaction to thunderstorms

Does your dog react to other noises?

Describe your dogs overall activity level

Behavioral Details

Please describe the main behavior problem

Describe a typical episode

Please answer the following questions for the main problem: How do you correct your dog after he/she does something wrong?

When did you first notice the problem?

Describe the first incident

Describe the most recent episode (include approximate date)

When did the problem become a serious concern? And why did you decide to seek the advise of a behaviorist?

Any household changes that occurred within 3 months of the onset of the problem?

What measures have you taken to correct the problem?

How do you generally discipline your dog? And your dogs typical response.

Please list any behavior problems or concerns you experience with your dog, please include frequency of problem/concern

Aggression Survey- Please answer the following if your dog has bitten a person

Age of dog and circumstances surrounding first snap or bite

Number of bites requiring medical attention

Who were the targets of the aggression

Body parts bitten

Is aggression predictable?

Do the attacks appear provoked?

Is the dog docile afterward?

Does the dog appear disoriented afterward?

Does the dog appear sorry afterward?

Do you notice a glazed expression during the attack?

How does your dog behave towards familiar visitors

How does your dog behave towards unfamiliar visitors

How does your dog behave towards children

Complete this sentence; My dog mounts

It occurs mainly

My dog mounts other animals or inanimate objects

My dog jumps up on family members or others without permission

My dog paws at family members

My dog barks at family members

My dog grooms itself excessively

My dog urinates/defecates indoors in unacceptable locations

How many weeks/months were required to train your dog?

Was a crate used?

Obedience Training

Puppy Kindergarten: Age During Classes

Group Obedience Classes

Private Instruction (age, name of trainer)

List show, obedience, and other working titles

Types of collar(s) used for training

Aggression Screen: (N/R = No Reaction N/A= Not Applicable)

Pet Dog

Hug Dog/Kiss Dog

Lift Dog

Approach Pet while Resting

Approach on Furniture

Call off furniture

Pull off furniture

Approach while eating

Touch while eating

Take dog food dish

Take water dish

Take human food or treat

Take rawhide or bone

Approach when has bone

Take toy or coveted object

Approach when dog is near his/her special person

Enter or leave room

Stare at dog

Speak to dog

Visually threaten the dog

Verbally punish

Physically punish

Give command to sit or down

Push into sit or down

Push on shoulder or rump

Restrain by leash

Restrain by collar

Put leash or collar on

Remove leash or collar

Reach for dog

Step over dog

Towel dry



Trim nails

With veterinarian

With groomer

Unfamiliar adult/child enters house/yard

Unfamiliar dog enters house/yard

Familiar adult/child enters house/yard

On leash-person approaches

On leash-dog approaches

In house people/dog pass

In car-toll booth or gas station

Response to infant/toddler

Response to squirrel/cat

Owner Information

What type of work does everyone in the house do?

Does anyone in the house have a medical problem? If yes please specify.

List all members of your household; ages of children, hours per day away from home

Does anyone take prescription medication? If yes please list what medications.

Describe your home

Have you relocated since you have owned this dog? If yes approximate date?

Please list all household pets in order of acquired: please include type of pet, breed, genders, current age, and age acquired

Call for an Appointment: (845) 651-3647 / (845) 651-DOGS

Contact Us:
Phone: (845) 651-3647 (DOGS)
Fax: (845) 508-6614

37 Grandview Place
Florida, NY 10921
By Appointment ONLY

Or Complete Our Contact Form to schedule a consultation
Before and After Videos
Frequently Asked Question
Why do dogs have separation anxiety?

Many people use the term, Separation anxiety as a catch all to describe a dog’s action given a particular situation.  There are really many types of separation anxiety and many causes for separation anxiety.  Below are just a few of them to give you an idea of the different types.   Since there are many types of separation anxiety, they cannot be treated the same.  Often books, TV shows and the internet; give ‘expert advice’ on how to treat separation anxiety, but without identifying the type and cause for the particular case, this is highly irresponsible and rarely affective.  This is also why simply placing the dog on a medication, rarely works.  The choice of what medication to use, if any, needs to be targeted to the specific type and cause of the dog’s separation anxiety, usually in conjunction with a modification program, to be truly effective.  When we have a client whose dog is suffering from this ailment, we conduct a detailed evaluation to determine the type and cause of the separation anxiety, then design a custom plan to reduce and resolve the problem.

Medical separation anxiety occurs when a dog has an ailment, often unknown to the owners, that causes an insecurity when they are left alone.  Since dogs cannot tell us how they are feeling, they speak to us through their behavior.  Unfortunately, it is not financially realistic for us to do body scans and MRI’s on our canine companions; this is often not discovered from a medical screening but can be recognized by a behavioral evaluation.

Geriatric separation anxiety occurs as a dog ages and during specific situations they become confused and react through behaviors that would be deemed separation anxiety.  Again, this is something that can be identified and treated through a behavioral consultation.

Specific triggered separation anxiety is another form.  This occurs when a dog develops an association towards a specific sight, sound or smell; that caused a traumatic reaction.  Often this manifests into other areas through something known as forward chaining and by the time the owner notices the dog suffering from separation anxiety, it has morphed far from the original issue.  This type of separation anxiety usually requires a behaviorist to evaluate the dog in order to determine the cause and develop a program to resolve the reaction.

Another big form of separation anxiety is dominance based or lack of leadership. If your dog does not feel you are the pack leader then the job of protecting the pack falls to them. Could you imagine how you would feel if you had a young child that you are responsible for and that child walked out of the house and disappeared without you knowing where they went and if they are safe or not. This is what the dog experiences every time you leave the house when they feel they are responsible for your safety. In order to stop the anxiety the dog has to know that you are in charge and not them. While living with us in our world a dog is not capable of being in charge and only can be well behaved and happy if it is clear that you are the alpha, capable of making decisions for the pack and ensuring the safety of the pack. In the wild when the alpha wolf goes out to hunt those that stay behind do not stress over his or her leaving because they are confident in their leadership and know they will return. The alphas comings and goings are never questioned it is their right to do so and canines operate with this same mentality.

This is by No means a complete list, but as you can see from just these few examples, separation anxiety is a complex disorder that cannot be handled through a ‘cookie cutter’ approach.  A dog suffering from this requires a behaviorist to conduct a scientific evaluation to determine what type of separation anxiety is occurring and why it started, so that a Proper modification program can be developed to resolve the behavior.  Often dog’s suffering from separation anxiety display severe behavior or causes substantial damage but the issue can be resolved once the type and cause is determined. We have had many cases where dogs were set to be euthanized or re-homed due to this disorder but after a few weeks of work the situation was resolved.


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