Canine Behavior Specialist
Canine Behavior Analysis
If you have questions and/or concerns regarding your dog's specific behavior opportunities, please fill out this form and submit it to us. Once received, we will review it and get back to you via phone or email within 48 hours.

The form is extensive, but all answers are important in order to properly evaluate the possible origins and reasons behind your dog's specific behavior issues.  If you have any questions about this form, please feel free to contact us before proceeding.
Pet Parent's Name
Email
Phone #
Dog's Name
Dog's Breed/Breeds
Dog's Age (approx. age OK)
Weight
Male
Female
Is your dog Spayed or Neutered? 
How long have you had the dog?
Age of pet when obtained
Where did you obtain this pet?
Name of Breeder (if known)
Behavior of parents and/or littermates (if known)
Does the pet have any medical problems?
List any medications the pet is currently taking
For what purpose was this pet obtained?
What are you currently feeding your dog?
When is your pet fed?
How often is your pet fed?
Where is your pet fed?
Who feeds your pet?
Describe how your pet eats (fast, picky, etc.)
List all treats given and frequency
How do you exercise your pet?
Amount and frequency of exercise:
Who exercises your dog?
Amount and frequency of play:
Who plays with the dog?
Favorite game:
Favorite toy:
Where does your dog stay when you are away during the day?
Where does your dog stay when you are home?
Where does your dog stay overnight?
Where does your dog stay when guests visit?
How long is the dog home alone each day?
Dog's reaction when left alone:
Reaction prior to departure:
Reaction at homecoming:
Is the dog ever alone outdoors?
How often?
How long is the dog alone outdoors (on average)?
Where is the dog left when outdoors?
How does your dog react to car rides?
Do you ever leave your dog alone in the car?
For how long?
What is your primary area of concern regarding your dog?
What do you consider to be the severity of the problem?
Have you considered euthanasia?
comment re: above question if necessary
Describe the problem, beginning with the most recent incident:
Describe previous incidents:
What age was your pet when this problem started?
Describe the first incident:
How often does this problem occur?
Has there been a recent change in frequency or severity?
If yes, describe:
Describe any changes in the home when the problem first appeared:
Have you actually seen the problem?
If yes, what did you do?
What has been done so far to try and correct the problem?
What was the dog's response?
List any techniques that have had success:
List any techniques that have made the problem worse:
List any drugs tried and the dog's reaction to the medication
Additional comments on principle problem:
List all family/household members including sex and age
Describe how your dog gets along with each family member:
Briefly describe the family schedule, including how long the dog is left alone:
List all other pets, including species, age, sex and whether each pet was obtained before or after the dog in question.
Describe how your pets get along with each other
Describe any obedience training given so far:
At what age did classes begin?
What was the outcome?
Describe your dog's learning ability (learns fast, gets distracted, etc.)
Who took the dog to training?
What commands are most successful?
In what location/situations are commands most successful:
What commands are least successful?
In what location/situations are commands least successful:
Which family members have best control?
Which family members have least control?
How would you describe your dog's personality?
My dog reacts negatively to: (select all that apply)
Nail trimming
Giving Medication
Cleaning ears
Grooming
Bathing
Patting Head
Rubbing Belly
Being Lifted
Rolling Over
Grasping Collar
Familiar dogs on property
Familiar dogs off property
Unfamiliar dogs on property
Unfamiliar dogs off property
Strangers on property
Strangers off property
Strangers arriving indoors
Other animals
Have you ever used a crate for confinement?
If yes, when?
Do you still use a crate?
How long was the crate used (if no longer used)
When and why did you stop (if applicable)
Describe the dog's reaction to being crated:
Was the crate ever used for punishments? (time outs, etc.)
Crate location:
Describe crate used (airline, wire, etc.)
I have used the following punishment methods (check all that apply)
Physical Punishment (hitting, spanking, etc.)
Noise Punishment (shaker can, siren, etc.)
Ultrasonics (dog whistle, sound collar)
Water sprayer/bottle
Verbal
Physical Handling
Muzzle Grasp
Roll-Over/Pinning
Time Out
What punishment has been most effective?
If any punishments made the problem worse, please describe:
Which family member is most successful at punishment?
Type of punishment used:
Which family member is least successful at punishment?
type of punishment used and dog's reaction to this person
Is your dog aggressive to family members?
If yes, list who and describe behavior
List any other people that your dog is aggressive toward:
List any types of people (children, delivery people, etc.) that your dog is aggressive toward:
Has your dog ever bitten hard enough to break the skin or cause injury?
If yes, describe:
Describe any situation where your dog growls:
Does your dog ever threaten or act aggressive in any of the following situations:
Petting
While Eating
Chewing Objects
Approach while sleeping
Punishment/Discipline
People entering home
People entering yard
People off property
Other dogs on property
Other dogs off property
Other animals
Describe any threatening or aggressive reactions to the above situations
Describe any particular type of handling (nail trimming, grooming, etc.) that leads to aggressing:
Was there an illness, injury or health problem when the aggression started?
Does handling a particular part of the body lead to aggression
When your dog is aggressive, what is your response?
If your dog acts fearful at the time of aggression, describe the situation and dog's reaction:
Masturbation (humps legs/objects)
Roaming
Mounting (other pets)
Urine Marking
Chews/Licks self frequently
Tail Biting
Tail Chasing
Fly Chasing
Uncontrollable Urination when Excited
Uncontrollable Urination when Frightened
Bedwetting (while sleeping)
Eats non-food items
Obsessively Licks Objects
Sleep Disorders
Excitability
Overactive
Phobias (thunder, cars, etc.)
Shyness/Timidity
Is there any additional information you would like us to know?
What do you think is the reason for your dog's problem?
Address
Does your dog exhibit any of the following behaviors (check all that apply)
Destructive Digging
Destructive Chewing
Barking
Howling
Whining
House Soiling
Stool Eating
Chasing Objects
Jumps Up (on guests)
Jumps Up (on owners)
On Furniture when not permitted
Garbage Raiding
Food Stealing
Pushy/Wants own way
Runs Away
Won't Come When Called
Only listens when he/she feels like it