Intake Form – 1 Dog

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Client Information

Name

Address

Email

Phone

Fax (optional)

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

Frequently Asked Question

Yes, we deal with your doctor on a regular basis. Any time we perform a behavioral consultation we send a behavioral report to your doctor in order to keep them involved with your overall dogs care.

In cases where clients have more severe problems requiring medication we will consult with your veterinarian to ensure your dog is placed on the right medication for the condition he / she has. We are educated in the latest veterinary psychopharmacology which allows us to assist your doctor to ensure the latest and most effective medications are utilized.

We are also available to consult with your doctor at any time, free of charge.

If you do not currently have a vet we will recommend one in your area.

See the entire answer

Intake Form – 1 Dog

Client Information

Name

Address

Email

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

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?

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?