Canine Case Squad Intake Form

Client Info (Required)
ALL FIELDS IN THIS SECTION ARE REQUIRED UNLESS OTHERWISE STATED

Name:  
   Last:

   First:
Address:  
  Street:
  City:  
  State:
  Zip: 
E-mail:

Telephone:

Fax: (optional)

   
Patient Info (First Dog)
Name:
Breed:
Gender:
Color:
Age:
Weight: (lbs)
Date of Birth: (if known)
   
   
Medical Information:
Animal Hospital:
Veterinarian:
Address:
Phone:
Referred By: (if other than veterinarian)
   

Chief Complaint:

What is your biggest problem?

 
 
Canine Medical History:
 
Is your dog spayed/neutered? (yes or 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:

 

Other Medications:
 
List conditions for which your dog has been treated, medication prescribed, and approximate dates:
 
Has there been any changes in your dogs appetite or water consumption EITHER UP OR DOWN? If so has this increased and when did it increase?
 
Has there been any change in your dogs stool?   YesNo
 
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?    YesNo
 
Does your dog stare at objects for long periods of time?   YesNo
 
Has the quality of your dogs coat changed?   YesNo
 
Is your dog scratching or biting him/herself?   YesNo
 
Has there been any changes to his/her sleeping pattern or location?   YesNo
 
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:

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 or no)
 
Does your dog run unsupervised outdoors? (yes or 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 or no)
 
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)? (yes or no)
 
Does your dog allow you to interrupt his eating? (yes or no)
 
Can anyone take the dogs food away? (yes or no)
 
Can anyone take away bone/treat? (yes or no)
 
Can anyone take away toys? (yes or 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 or 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 or no)
 
Do the attacks appear provoked? (yes or no)
 
Is the dog docile afterward? (yes or no)
 
Does the dog appear disoriented afterward? (yes or no)
 
Does the dog appear sorry afterward? (yes or no)
 
Do you notice a glazed expression during the attack? (yes or 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 or no)
 
My dog jumps up on family members or others without permission: (yes or no)
 
My dog paws at family members: (yes or no)
 
My dog barks at family members: (yes or no)
 
My dog grooms itself excessively: (yes or no)
 
My dog urinates/defecates indoors in unacceptable locations: (yes or no)
 
How many weeks/months were required to train your dog?
 
Was a crate used? (yes or 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)
  Action Reaction
1 Pet Dog  
2 Hug Dog/Kiss Dog  
3 Lift Dog  
4 Approach Pet while Resting  
5 Approach on Furniture  
6 Call off furniture  
7 Pull off furniture  
8 Approach while eating  
9 Touch while eating  
10 Take dog food dish  
11 Take water dish  
12 Take human food or treat  
13 Take rawhide or bone  
14 Approach when has bone  
15 Take toy or coveted object  
16 Approach when dog is near his/her special person  
17 Enter or leave room  
18 Stare at dog  
19 Speak to dog  
20 Visually threaten the dog  
21 Verbally punish  
22 Physically punish  
23 Give command to sit or down  
24 Push into sit or down  
25 Push on shoulder or rump  
26 Restrain by leash  
27 Restrain by collar  
28 Put leash or collar on  
29 Remove leash or collar  
30 Reach for dog  
31 Step over dog  
32 Towel dry  
33 Brush  
34 Bathe  
35 Trim nails  
36 With veterinarian  
37 With groomer  
38 Unfamiliar adult/child enters house/yard  
39 Unfamiliar dog enters house/yard  
40 Familiar adult/child enters house/yard  
41 On leash-person approaches  
42 On leash-dog approaches  
43 In house people/dog pass  
44 In car-toll booth or gas station  
45 Response to infant/toddler  
46 Response to squirrel/cat  

Patient Info (Second Dog if applicable)
Name:
Breed:
Gender:
Color:
Age:
Weight: (lbs)
Date of Birth: (if known)
   
   
Medical Information:
Animal Hospital:
Veterinarian:
Address:
Phone:
Referred By: (if other than veterinarian)
   

Chief Complaint:

What is your biggest problem?

 
 
Canine Medical History:
 
Is your dog spayed/neutered? (yes or 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:

 

Other Medications:
 
List conditions for which your dog has been treated, medication prescribed, and approximate dates:
 
Has there been any changes in your dogs appetite or water consumption EITHER UP OR DOWN? If so has this increased and when did it increase?
 
Has there been any change in your dogs stool?   YesNo
 
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?    YesNo
 
Does your dog stare at objects for long periods of time?   YesNo
 
Has the quality of your dogs coat changed?   YesNo
 
Is your dog scratching or biting him/herself?   YesNo
 
Has there been any changes to his/her sleeping pattern or location?   YesNo
 
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:

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 or no)
 
Does your dog run unsupervised outdoors? (yes or 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 or no)
 
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)? (yes or no)
 
Does your dog allow you to interrupt his eating? (yes or no)
 
Can anyone take the dogs food away? (yes or no)
 
Can anyone take away bone/treat? (yes or no)
 
Can anyone take away toys? (yes or 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 or 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 or no)
 
Do the attacks appear provoked? (yes or no)
 
Is the dog docile afterward? (yes or no)
 
Does the dog appear disoriented afterward? (yes or no)
 
Does the dog appear sorry afterward? (yes or no)
 
Do you notice a glazed expression during the attack? (yes or 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 or no)
 
My dog jumps up on family members or others without permission: (yes or no)
 
My dog paws at family members: (yes or no)
 
My dog barks at family members: (yes or no)
 
My dog grooms itself excessively: (yes or no)
 
My dog urinates/defecates indoors in unacceptable locations: (yes or no)
 
How many weeks/months were required to train your dog?
 
Was a crate used? (yes or 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)
 
  Action Reaction
1 Pet Dog  
2 Hug Dog/Kiss Dog  
3 Lift Dog  
4 Approach Pet while Resting  
5 Approach on Furniture  
6 Call off furniture  
7 Pull off furniture  
8 Approach while eating  
9 Touch while eating  
10 Take dog food dish  
11 Take water dish  
12 Take human food or treat  
13 Take rawhide or bone  
14 Approach when has bone  
15 Take toy or coveted object  
16 Approach when dog is near his/her special person  
17 Enter or leave room  
18 Stare at dog  
19 Speak to dog  
20 Visually threaten the dog  
21 Verbally punish  
22 Physically punish  
23 Give command to sit or down  
24 Push into sit or down  
25 Push on shoulder or rump  
26 Restrain by leash  
27 Restrain by collar  
28 Put leash or collar on  
29 Remove leash or collar  
30 Reach for dog  
31 Step over dog  
32 Towel dry  
33 Brush  
34 Bathe  
35 Trim nails  
36 With veterinarian  
37 With groomer  
38 Unfamiliar adult/child enters house/yard  
39 Unfamiliar dog enters house/yard  
40 Familiar adult/child enters house/yard  
41 On leash-person approaches  
42 On leash-dog approaches  
43 In house people/dog pass  
44 In car-toll booth or gas station  
45 Response to infant/toddler  
46 Response to squirrel/cat  

Patient Info (Third Dog if applicable)
Name:
Breed:
Gender:
Color:
Age:
Weight: (lbs)
Date of Birth: (if known)
   
   
Medical Information:
Animal Hospital:
Veterinarian:
Address:
Phone:
Referred By: (if other than veterinarian)
   

Chief Complaint:

What is your biggest problem?

 
 
Canine Medical History:
 
Is your dog spayed/neutered? (yes or 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:

 

Other Medications:
 
List conditions for which your dog has been treated, medication prescribed, and approximate dates:
 
Has there been any changes in your dogs appetite or water consumption EITHER UP OR DOWN? If so has this increased and when did it increase?
 
Has there been any change in your dogs stool?   YesNo
 
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?    YesNo
 
Does your dog stare at objects for long periods of time?   YesNo
 
Has the quality of your dogs coat changed?   YesNo
 
Is your dog scratching or biting him/herself?   YesNo
 
Has there been any changes to his/her sleeping pattern or location?   YesNo
 
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:

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 or no)
 
Does your dog run unsupervised outdoors? (yes or 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 or no)
 
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)? (yes or no)
 
Does your dog allow you to interrupt his eating? (yes or no)
 
Can anyone take the dogs food away? (yes or no)
 
Can anyone take away bone/treat? (yes or no)
 
Can anyone take away toys? (yes or 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 or 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 or no)
 
Do the attacks appear provoked? (yes or no)
 
Is the dog docile afterward? (yes or no)
 
Does the dog appear disoriented afterward? (yes or no)
 
Does the dog appear sorry afterward? (yes or no)
 
Do you notice a glazed expression during the attack? (yes or 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 or no)
 
My dog jumps up on family members or others without permission: (yes or no)
 
My dog paws at family members: (yes or no)
 
My dog barks at family members: (yes or no)
 
My dog grooms itself excessively: (yes or no)
 
My dog urinates/defecates indoors in unacceptable locations: (yes or no)
 
How many weeks/months were required to train your dog?
 
Was a crate used? (yes or 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)
 
  Action Reaction
1 Pet Dog  
2 Hug Dog/Kiss Dog  
3 Lift Dog  
4 Approach Pet while Resting  
5 Approach on Furniture  
6 Call off furniture  
7 Pull off furniture  
8 Approach while eating  
9 Touch while eating  
10 Take dog food dish  
11 Take water dish  
12 Take human food or treat  
13 Take rawhide or bone  
14 Approach when has bone  
15 Take toy or coveted object  
16 Approach when dog is near his/her special person  
17 Enter or leave room  
18 Stare at dog  
19 Speak to dog  
20 Visually threaten the dog  
21 Verbally punish  
22 Physically punish  
23 Give command to sit or down  
24 Push into sit or down  
25 Push on shoulder or rump  
26 Restrain by leash  
27 Restrain by collar  
28 Put leash or collar on  
29 Remove leash or collar  
30 Reach for dog  
31 Step over dog  
32 Towel dry  
33 Brush  
34 Bathe  
35 Trim nails  
36 With veterinarian  
37 With groomer  
38 Unfamiliar adult/child enters house/yard  
39 Unfamiliar dog enters house/yard  
40 Familiar adult/child enters house/yard  
41 On leash-person approaches  
42 On leash-dog approaches  
43 In house people/dog pass  
44 In car-toll booth or gas station  
45 Response to infant/toddler  
46 Response to squirrel/cat  

Owner History
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


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:


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