Intake Form – 3 Dogs

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Client Information

Name

Address

Email

Phone

Fax (optional)

Patient Info - (Dog 1 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)

Pet Dog

Hug Dog/Kiss Dog

Lift Dog

Approach Pet while Resting

Approach on Furniture

Call off furniture

Pull off furniture

Approach while eating

Touch while eating

Take dog food dish

Take water dish

Take human food or treat

Take rawhide or bone

Approach when has bone

Take toy or coveted object

Approach when dog is near his/her special person

Enter or leave room

Stare at dog

Speak to dog

Visually threaten the dog

Verbally punish

Physically punish

Give command to sit or down

Push into sit or down

Push on shoulder or rump

Restrain by leash

Restrain by collar

Put leash or collar on

Remove leash or collar

Reach for dog

Step over dog

Towel dry

Brush

Bathe

Trim nails

With veterinarian

With groomer

Unfamiliar adult/child enters house/yard

Unfamiliar dog enters house/yard

Familiar adult/child enters house/yard

On leash-person approaches

On leash-dog approaches

In house people/dog pass

In car-toll booth or gas station

Response to infant/toddler

Response to squirrel/cat

Patient Info - (Dog 2 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)

Pet Dog

Hug Dog/Kiss Dog

Lift Dog

Approach Pet while Resting

Approach on Furniture

Call off furniture

Pull off furniture

Approach while eating

Touch while eating

Take dog food dish

Take water dish

Take human food or treat

Take rawhide or bone

Approach when has bone

Take toy or coveted object

Approach when dog is near his/her special person

Enter or leave room

Stare at dog

Speak to dog

Visually threaten the dog

Verbally punish

Physically punish

Give command to sit or down

Push into sit or down

Push on shoulder or rump

Restrain by leash

Restrain by collar

Put leash or collar on

Remove leash or collar

Reach for dog

Step over dog

Towel dry

Brush

Bathe

Trim nails

With veterinarian

With groomer

Unfamiliar adult/child enters house/yard

Unfamiliar dog enters house/yard

Familiar adult/child enters house/yard

On leash-person approaches

On leash-dog approaches

In house people/dog pass

In car-toll booth or gas station

Response to infant/toddler

Response to squirrel/cat

Patient Info - (Dog 3 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)

Pet Dog

Hug Dog/Kiss Dog

Lift Dog

Approach Pet while Resting

Approach on Furniture

Call off furniture

Pull off furniture

Approach while eating

Touch while eating

Take dog food dish

Take water dish

Take human food or treat

Take rawhide or bone

Approach when has bone

Take toy or coveted object

Approach when dog is near his/her special person

Enter or leave room

Stare at dog

Speak to dog

Visually threaten the dog

Verbally punish

Physically punish

Give command to sit or down

Push into sit or down

Push on shoulder or rump

Restrain by leash

Restrain by collar

Put leash or collar on

Remove leash or collar

Reach for dog

Step over dog

Towel dry

Brush

Bathe

Trim nails

With veterinarian

With groomer

Unfamiliar adult/child enters house/yard

Unfamiliar dog enters house/yard

Familiar adult/child enters house/yard

On leash-person approaches

On leash-dog approaches

In house people/dog pass

In car-toll booth or gas station

Response to infant/toddler

Response to squirrel/cat

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

Call for an Appointment: (845) 651-3647 / (845) 651-DOGS

Contact Us:
Phone: (845) 651-3647 (DOGS)
Fax: (845) 508-6614

FACILITY
37 Grandview Place
Florida, NY 10921
By Appointment ONLY


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Frequently Asked Question
What is a Behaviorist? What do they do?
A behaviorist is responsible for evaluating a dog to determine what problems are going on,…

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