Your Information
Dog Info
Dog Medical Information
Background Information
Behavioral Details
Agression Survey
Obedience Training
Additional Information
Client Information
Patient Info (Dog Info)
Gender
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?
MANAGEMENT
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