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Why did you decide to get a dog? Why did you choose this breed or mix?
How many dogs did you have to choose from? Why did you pick this dog?
Where did you get this dog (breeder, pet store, shelter, friend, etc.)?
How many littermates did your dog have? Any information about their behavior?
Any information about the dog's parents behavior?
Have you owned dogs before? How many?
Has this dog had other owners? If so, why was it given up?
Is your dog spayed or neutered? Any behavior changes after the operation?
Do you plan to breed your dog?
For intact females, was the last heat normal?
Nutrition and Exercise: What do you feed your dog (brand and type)?
How much do you feed? How many times daily?
Who feeds the dog? Where?
What is your dog's favorite treat?
How long is your dog alone on an average day?
How do you exercise your dog?
When outdoors, how is your dog confined (fence, electric fence, tie-out, leash, runs free)?
What are your dog's favorite toys and games?
How would you describe your dog's activity level (low, average, high, very high)? Behavior:
Where is your dog when alone in the house?
Where does your dog sleep?
Where is your dog when you have guests?
How does your dog behave with familiar visitors?
With unfamiliar visitors?
Is your dog housetrained?
Were there any housetraining problems? Please describe.
How does your dog behave when you leave the house?
When you return?
Please indicate "yes" for any of the listed behaviors that your dog does to you or others, without permission	Jump up Paw Lick Mount
Does your dog mount other animals or objects? Please describe.
Does your dog bark at you? When?
Does your dog bark at other times? Please describe.
Does your dog show fearful behavior (hiding, whining, tensing or backing up, lowered ears or tail, refusal to interact) around people? Please indicate if this is with respect to a particular age, gender or physical type.
Does your dog show fearful behavior around other dogs? Any particular breed, gender or size?
Does your dog show fearful behavior in response to particular objects or in particular situations? Please describe.
Does your dog show fearful responses to thunderstorms or to loud noises? Please describe.
Training: Has your dog had obedience training? Please describe behaviors learned, training program (private or group) and methods (leash corrections, electronic collar, food rewards, clicker training, etc.).
Has your dog earned any awards for obedience or dog sports? Please specify.
What percentages of the time will the dog obey the listed commands?	Sit: Down: Come: Heel:
Who in the family is the primary trainer?
Does your dog have any special talents or tricks? Please describe.
Medical History: Is your dog on any medication? Please specify condition being treated, type of medication and dosage.
Had your dog been on medication in the past? For what condition(s)?
Date of last rabies vaccination.
Has your dog had any physical injuries or disabilities? When? Please describe the type, treatment and outcome. Bite History:
Has your dog ever bitten a person or another animal? Who or what was the target?
How many times has your dog bitten and broken skin? Was medical treatment required?
Were the bites reported to animal control?
How many times has your dog bitten and not broken skin? Please provide details.

Please enter "yes" in the boxes for any of the following that are characteristic of your dog’s bite/aggression history: Attacks are sudden and surprising Episodes appear unprovoked Dog is abruptly docile after an episode Dog appears disoriented afterwards Episodes are associated with a “glazed” expression I can usually tell what will set my dog off Aggressive behavior is new and uncharacteristic

Please read through the list of situations that may elicit aggressive signals. For any situations that apply to your dog, indicate in the "reaction" column the type of aggressive display--bark, snarl, growl, air snap or bite that has occurred. Use the "comments" column for information about the targets of the aggressive displays (e.g., husband, strangers, etc.). You may provide additional comments at the end of the form.

How old was the dog when you first noticed the main problem?
When did it first become a serious concern?
Has this problem changed in frequency? How?
Has this problem changed in intensity? How?
Please describe the most recent incident.
What have you done to correct the problem?
If these problems are not resolved, will you be able to keep the dog in your family? Please explain Family Information:
Please list all family members; include ages of children.
Please list all other animals in the home (species, breed, sex, age when obtained, and age now).
What is your dog's behavior toward the other animals?
Have you moved since acquiring your dog? How many times?
Has your household changed since acquiring your dog? How?

Situation	Reaction	Comments
Take dog’s food dish with food
Take dog’s empty food dish
Take dog’s water dish
Take human food that falls on floor
Take rawhide
Take real bone
Take biscuit
Take toy
Human approaches dog while eating
Dog approaches dog while eating
Human approaches dog while playing with toys
Dog approaches dog while playing with toys
Human approaches/disturbs dog while sleeping
Dog approaches/disturbs dog while sleeping
Step over dog
Push dog off bed/couch
Reach toward dog
Reach over head
Put on leash
Human pushes on shoulders
Dog mounts, pushes on shoulders
Human pushes on rump
Towel feet when wet
Bathe dog
Groom dog’s head
Groom dog’s body
Human stares at dog
Dog stares at dog
Take muzzle in hands and shake
Push dog over onto back
Stranger knocks on door
Stranger enters room
Dog in car at toll booth
Dog in car at gas station
Dog on leash approached by dog on street
Dog on leash approached by person on street
Dog in yard when person passes
Dog in yard when dog passes
Dog in vet’s office
Dog in boarding kennel
Dog at groomer
Dog is yelled at
Dog corrected with leash
Dog physically punished or hit
Someone raises voice to owner in presence of dog
Someone hugs or touches owner in presence of dog
Squirrels, cats or other small animals approach
Dog sees bicycles or skateboards
Dog sees crying infant
Dog plays with toddlers
Dog plays with 5-7 year old children
Dog plays with 8-11 year old children
Dog plays with 12-16 year old children