Intake Form – 1 Dog
Client Information
Name
Address
Phone
Fax (optional)
Patient Info (Dog Info)
Dog Name
Breed
Gender
Color
Age
Weight
Date of Birth
Medical Information
Animal Hospital
Veterinarian
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
MANAGEMENT
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)
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