Intake Form – 1 Dog
Intake Form – 1 Dog
Canine Case Squad Intake Form
Client Information (Required)
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Email
*
Phone
*
-
(###)
-
###
####
Fax (optional)
-
(###)
-
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Patient Info (Dog Info)
Name
Breed
Gender
Male
Female
Color
Age
Weight
Date of Birth
/
MM
/
DD
YYYY
Medical Information
Animal Hospital
Veterinarian
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Phone
-
(###)
-
###
####
Referred By
Chief Complaint
What is your biggest problem?
Canine Medical History
Is your dog spayed/neutered?
Yes
No
If yes, at what age was the procedure performed, reason for procedure, and finally any behavioral changes after procedure?
Provide dates for most recent vaccinations, if applicable:
Rabies
Lyme Vaccine
Canine Distemper
Leptospirosis
Please check all current medications
Heartworm prevention
Flea/Tick/Mite Control
Antihistamine
Anti-inflammatory
Thyroid Hormone
Antibiotic
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?
Yes
No
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?
Yes
No
Does your dog stare at objects for long periods of time?
Yes
No
Has the quality of your dogs coat changed?
Yes
No
Is your dog scratching or biting him/herself?
Yes
No
Has there been any changes to his/her sleeping pattern or location?
Yes
No
Background Information
Date (approximate) you acquired your dog
/
MM
/
DD
YYYY
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:
Describe the temperament of the dogs father:
Do you know the status of your dogs littermates?
Describe your dogs relationship to other animals within the household:
Management
Please describe a typical 24 hour day in the life of your dog:
Typically what percentage of the day does your dog spend indoors?
Do you have a fenced yard?
Yes
No
Does your dog run unsupervised outdoors?
Yes
No
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?
Yes
No
Sometimes
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?
One
Two
Three or more
Do you leave food down for him/her to eat during the day (graze eating)?
Yes
No
Does your dog allow you to interrupt his eating?
Yes
No
Can anyone take the dogs food away?
Yes
No
Can anyone take away bone/treat?
Yes
No
Can anyone take away toys?
Yes
No
Which family members are responsible for feeding?
Location of bowl(s):
When does your dog eat "table food"?
Dogs favorite treats
Describe your dogs reaction to thunderstorms:
Does your dog react to other noises?
Yes
No
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?
Yes
No
Do the attacks appear provoked?
Yes
No
Is the dog docile afterward?
Yes
No
Does the dog appear disoriented afterward?
Yes
No
Does the dog appear sorry afterward?
Yes
No
Do you notice a glazed expression during the attack?
Yes
No
How does your dog behave towards visitors?
familiar visitors
unfamiliar visitors
children
Complete the sentence:
My dog mounts
It occurs mainly
My dog mounts other animals or inanimate objects
Yes
No
My dog jumps up on family members or others without permission
Yes
No
My dog paws at family members
Yes
No
My dog barks at family members
Yes
No
My dog grooms itself excessively
Yes
No
My dog urinates/defecates indoors in unacceptable locations
Yes
No
How many weeks/months were required to train your dog?
Was a crate used?
Yes
No
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
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Hug Dog/Kiss Dog
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Lift Dog
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Approach Pet while Resting
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Approach on Furniture
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Call off furniture
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Pull off furniture
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Approach while eating
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Touch while eating
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Take dog food dish
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Take water dish
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Take human food or treat
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Take rawhide or bone
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Approach when has bone
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Take toy or coveted object
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Approach when dog is near his/her special person
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Enter or leave room
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Stare at dog
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Speak to dog
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Visually threaten the dog
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Verbally punish
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Physically punish
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Give command to sit or down
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Push into sit or down
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Push on shoulder or rump
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Restrain by leash
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Restrain by collar
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Put leash or collar on
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Remove leash or collar
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Reach for dog
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Step over dog
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Towel dry
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Brush
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Bathe
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Trim nails
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
With veterinarian
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
With groomer
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Unfamiliar adult/child enters house/yard
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Unfamiliar dog enters house/yard
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Familiar adult/child enters house/yard
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
On leash-person approaches
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
On leash-dog approaches
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
In house people/dog pass
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
In car-toll booth or gas station
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Response to infant/toddler
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Response to squirrel/cat
No Reaction
Snarl
Growl
Bite/Snap
Bark
Not Applicable
Owner History
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.
Home Environment:
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:
What media player do you have on your computer (what format do you prefer)?