Intake Form – 1 Dog

Your Information

Dog Info

Dog Medical Information

Background Information

Behavioral Details

Agression Survey

Obedience Training

Additional Information

  • Step 1
  • Step 2
  • Step 3
  • Step 4
  • Step 5
  • Step 6
  • Step 7
  • Final

Client Information

Patient Info (Dog Info)


Medical Information

Canine Medical History

Is your dog spayed/neutered?

Please check all current medications

Has there been any change in your dogs stool?

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

Background Information

Have you owned pets before?


Do you have a fenced yard?

Does your dog run unsupervised outdoors?

Does your dog usually follow you from room to room?

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?

Does your dog react to other noises?

Behavioral Details

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

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?

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

Was a crate used?

Obedience Training

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

Owner Information