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

Country
Email *
Phone * - (###) - ### ####
Fax (optional) - (###) - ### ####
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

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)?

Intake Form – 1 Dog

Intake Form – 1 Dog

Client Information (Required)

Patient Info (Dog Info)

Medical Information

Chief Complaint

Canine Medical History

Provide dates for most recent vaccinations, if applicable:

Background Information

Management

Behavioral Details

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

How does your dog behave towards visitors?

Complete the sentence:

Obedience Training:

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

Owner History

Home Environment: