TLC K9 Academy
Canine Behavior Consultation Questionnaire

GENERAL INFORMATION

*First Name:

*Last Name:

Address:

City:

State:

Postal (zip) code:

Home Phone:

*e-mail:

Business Phone:

Fax:

Veterinarian/clinic:

Clinic Phone:

Referred by:

PET INFORMATION

Dog's name:

Breed:

Color:

Date of birth:

Weight:

Sex:

Neutered?:

Age neutered:

Any change after neutering?:

Age pet obtained:

Where did you obtain this pet?:
Pet store stray Breeder shelter Friend Newspaper ad
Other:

Breeder, if applicable:

Behavior of parents or littermates:

REASON(S) FOR PRESENTATION

Please list behavior problems in order of importance:

Problem:

Rate:

Length of time
problem has
existed:

Frequency of problem
(e.g. once weekly, daily)

1.

severe
moderate
mild

2.

severe
moderate
mild

3.

severe
moderate
mild

INFORMATION ON PRESENTING COMPLAINT(S)

What do you think has caused the problem(s):

Describe the problem/misbehavior - last incident: (make sure to include such descriptions (if possible) of the dog's body posture, locations of other people or animals in the vicinity, circumstances that you believe stimulated the problem, etc.)

Describe previous incidents:

Has there been a recent change in frequency of the behavior?

What has been done so far to try and correct the problem?

What has been the dogs response?

List any techniques that have been successful:

List any techniques that have made the problem worse:

List any drugs that have been tried so far and the dog's response to the medication:

List any other dietary treatments, supplements or remedies and the dogs response:

FAMILY / RELATIONSHIPS

List each family member: (including sex and age)

Name:

Sex:

Age:

Male   Female

Male   Female

Male   Female

Male   Female

Male   Female

Male   Female

Male   Female

How does your dog get along with each member of the family?

Who feeds?

Who plays?

Who grooms?

Who gives treats?

Who trains?

Describe the family schedule, including how long the dog is left alone:

List all the pets in your household:

How do the pets get along with each other?

TRAINING

Any formal training? YES  NO

Class   Private Instructor  Trained at home

How successful was training?

Is there any ongoing training? YES  NO

If yes, describe:

Type of training collar used: (check one)

Dog's response:

Neck collar

Remote collar
(if yes, indicate type e.g. shock, citronella, etc.)

Head halter (Gentle Leader®, Halti®)

Body harness

Other (pinch, prong)

How would you describe the training?

Reward-based  Assertive/domineering   Aversive/mostly corrections  Other

How well does your dog obey the following commands (when asked for the FIRST time) for each household member? (list as a percent)

Is there any other commands or tricks your dog knows?

PUNISHMENT

Have you ever used any of
the following for punishment?

YES/NO

Reaction

1. Physical punishment?

YES  NO

2. Noise punishment (shaker can, siren)

YES  NO

3. Ultrasonic (Petagree®)

YES  NO

4. Water Sprayer:

YES  NO

5. Verbal reprimands:

YES  NO

6. Physical handling: muzzle grasp

YES  NO

pinning

YES  NO

7. Time out:

YES  NO

8. Bobby traps/repellents:

YES  NO

HANDLING

How does your dog react to the following types of handling?

Nail trimming:

Giving pills:

Brushing:

Hugging/kissing:

Rubbing belly:

Patting head:

Grabbing collar:

Lifting:

Rolling over:

Bathing:

MEDICAL SCREEN

Is there any past illness or present illness currently under treatment?

Any apparent painful conditions? YES   NO

Describe appetite: Voracious  Normal  Finicky  Decreased

Any changes in stool? YES   NO

Any changes in drinking? More   Less   Same

Any change in urination? Same  More frequently  Less frequently Larger volumes Smaller Volumes

Any food tolerances? YES   NO

If so, what?

Is your pet on any other medications? (besides the drugs listed under primary behavior complaint if any)

REINFORCER ASSESSMENT

If your dog was allowed any treat, what would it prefer? (List top five)

1.

2.

3.

4.

What other types of rewards does your dog enjoy? (play toys, walks, attention / affection). List top five:

1.

2.

3.

4.

HOUSETRAINING SCREEN
(Skip this section- if your pet is not housesoiling, )

Was your dog ever completely housetrained? YES   NO

At what age was he/she considered housetrained?

How often does your pet housesoil? (i.e. several x/day, weekly, or monthly, etc.)

Is it urine, stool or both?

When is the dog most likely to housesoil?

Do you have a doggie door? YES   NO

Does your dog use the doggie door? YES   NO

In what rooms does your dog tend to soil?

Is there a room/location in which the dog does NOT soil?

Does your dog soil when when family members are home?

Does your dog soil directly in front of a family member?

What do you do when you find urine or stool in an improper location?

Does your dog urine mark? (urinate on upright objects)

How many times per day does your dog have a chance to go outside to eliminate?

How long is the longest confinement without access to outside? (if any)

Is your dog crated? YES   NO    Is there urine in the crate? YES   NO

Does your dog leak urine when: Sleeping Walking Approached by owner
If approached by a stranger Excited Frightened

DEPARTURE BEHAVIOR SCREEN

How long is the dog left alone on an average day?

Is the dog left: Outdoors Access to both

Is your dog crated or confined on departure? YES   NO

If crated, describe crate: Location of crate?

If confined other than a crate, please describe:

Has your dog been left at a kennel, veterinary clinic or with family/friends?
If yes, describe your dogs reaction:

Does your dog exhibit any problem behaviors on your departures? YES   NO

If no please skip this remaining section; If yes continue with the following questions.

Describe your dog's behavior when left alone:

Does the behavior differ depending on the length of departure or the time of day left alone?

How does your dog act as you or other family members are getting ready to leave? Describe:

Does the behavior differ depending on who is the last to leave the home?

How does the dog react when the family returns?

Have you ever left the dog alone in the car? If so how did it react?

AGGRESSION SCREEN

Has your pet displayed any of the following?

Threatening display? YES   NO
Growling? YES   NO
Bite attempts? YES   NO
Bites? YES   NO

Skip the next section if your pet has displayed any of the above, but they have been resolved, or controlled to your satisfaction.

Skip this section and move to the next if your pet is not aggressive towards people.

Aggression Towards People

In your opinion, what is the potential for injury to another person?

Has your dog ever bitten hard enough to break skin or cause injury? YES   NO
If yes, describe:

Number of bites that have broken skin:

Body parts typically bitten:

If your dog has bitten a person, how old was the dog the first time he/she bit? (months or years)

Is your dog ever aggressive to members of the immediate family? YES   NO
If yes, who? Describe:

Is your dog ever aggressive to visitors in your home? YES   NO
If yes, who? Describe:

Is your dog aggressive to people off your property? YES   NO
If yes, where the people known, strangers or both? Explain:

Is there a particular person or type (age, sex, uniforms) that your dog is most likely to threaten or bite?

Is there a particular location or situation where aggression is most likely to occur?

When your dog threatens, attempts to bite or bites, how do you handle the situation and what is the dog's reaction?

How would you describe your dog's expression and postures at the time of aggression? (hackles raise, ear forward, tail back, tail up or tucked between legs and under, cowering, running forward and then retreating):

Skip this section and move to the next if your dog is not aggressive towards other dogs.

Aggression Towards Other Dogs

In your opinion, what is the potential for injury to another dog?

How old was your dog when you first noticed aggression to other dog(s)? (months or years)

Has your dog ever bitten hard enough to break skin or cause injury requiring medical attention? YES   NO

Number of bites that have broken skin

Body parts typically bitten:

Is there a particular location or situation where aggression is most likely to occur?

SUBMIT QUESTIONNAIRE