Behavior Assessment Intake Form Please complete this form before our initial assessment. Help Me Learn About Your DogDOG INFORMATION: Please fill out a separate questionnaire for each dog in your home. Even if only one dog needs training, it's important to know what might be influencing the dog being assessed. PRIVACY: All information is strictly confidential and never given to a third party! Date Your dog's name:Birthday:Age:Breed:Where did you acquire your dog?BreederShelterRescueAge when brought home:Sex:FemaleMaleSpayed or neutered:YesNoDon't knowLast veterinarian checkup: Veterinarian:Please list medications your dog is taking for chronic or acute conditions:How many other animals in your home?Please enter a number from 0 to 20.Help Me Learn About YouYour name: First Last Suffix List names of other members of your household:Best email address to contact: Best phone number to use:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Behavior InformationHow would you describe your dog's personality? Playful Happy Confident Excited Nervous Quick Mouthy Pushy Fearful Shy Aggressive Vicious Percent of time spent indoors:102030405060708090100Percent of time spent outdoors:102030405060708090100Has your dog ever bitten someone?YesNoHow many times?Please enter a number from 1 to 100.Under what circumstances did your dog bite?Did the person visit a doctor for this bite(s)?YesNoHas your dog ever bitten another dog?YesNoHow many times?Please enter a number from 1 to 100.Under what circumstances did your dog bite the other dog?Did either dog go to the vet for this bite(s)?YesNoWhat formal training has your dog had? Select All Puppy kindergarten Canine Good Citizen Obedience Private behavior modification What cues does your dog reliably respond to? Select All Come Down/Settle Drop it Focus Gentle Go to [place] Leave it Sit Wait and/or Stay What does your dog eat most of the time? Brand-name dog food Canned food Formula Freeze dried Kibble Raw Home-prepared How long on this food regimen?Who feeds your dog?How often does your dog eat?Please enter a number from 0 to 12.What kind of exercise does your dog receive? Agility Dog play Games Runs Walks What are your dog’s favorite toys?Are you generally involved in play?YesNoWhat type of discipline you regularly use?Describe what you use and what techniques seem to work best.Describe a typical 24-hour day for your dog:Household changes since you acquired your dog: Birth Death Divorce Change in schedule Doggie daycare Housemate came/left Kids off to college Move Traumatic event What upsets your dog, and how does your dog show it?Be specific, please.Describe the current problem(s) as it now occurs, and how long you have noticed the behavior(s)?What have you done to date to correct these issues?What are characteristics you would like to see in your dog for a calmer, more peaceful life with them?ReferrerHow did you hear about Your Canine Resource?Friend referralYelpVeterinarian referralWeb searchLet's Get Started!Thank you for taking the time to fill out this behavior assessment form! I'll review it before our actual assessment. Your training specialist, Patti L. Howard, BS, CCS Owner, Certified Trainer, Behavior Modification and Nutrition Consultant firstname.lastname@example.org | 360-929-1719PhoneThis field is for validation purposes and should be left unchanged. Save and continue later This iframe contains the logic required to handle Ajax powered Gravity Forms.