Your answers on this questionnaire give me the information I need to assess my ability to help you.

Please take the time to fill it out thoroughly and carefully. The information you provide serves as the essential core of the training goals we design and accomplish.

If your dog has had any issues with aggression towards people, I recommend that you have your dog evaluated by a qualified animal behaviorist, in the area where you live.

Aggression towards humans needs be addressed by a trainer who can do the evaluation and training in person, either in your home or their facility.

General Information

Your name: _________________ _________________
Address: _________________ _________________
Zip Code:
Home phone: _________________
Work/Day phone: _________________
Email address:

Name of dog: Breed: Dog’s date of Birth

Sex (spayed or neutered? Yes No )

What behaviors or skills you most would like your dog to learn (please list and be specific):




Please describe any hopes or aspirations you have for your dog beyond his/her being a family pet (such as dog sports or competition obedience, showing in confirmation classes or breeding, service or assistance with your physical limitations or specific disabilities, therapy dog for hospital visitation programs)?





HOME ENVIRONMENT:



Please list the people, including yourself, living in your household. Please include ages of children or grandchildren:

Names Ages Hours at work or school each day?





Approximately how much time does your dog spend each day without human companionship?


Please list all animals in the household including the one you would like help training.

Name Species Breed Sex Age Obtained Age Now




In what sequence were the above animals obtained? (Please number animals in the table above.)
What is your dog's relationship to the other animals
(e.g. friendly, hostile, fearful)? Please describe:






What type of area do you live in? (Circle one) City/Town Suburbs Rural

What type of house do you live in? Apartment Rented house Do you own your own home?


Have you moved since acquiring your dog? _____no _____yes
How many times? ________

Has your household (people or animals) changed since acquiring your dog?
_____no _____yes, please describe:


DOG’S BACKGROUND:


Why did you decide to get a dog?


Why did you choose this breed?


Where did you get this dog ( check or circle one): SPCA(animal shelter) Breeder-newspaper ad/flyer Breeder - referral Pet store Friend Stray Other: ______
Have you owned dogs before? _______yes ________no

If known: how many littermates did your dog have? males ________ females ________

How many animals did you have to choose from? ________________________
Why did you choose this dog over the others (please be specific):


Was a temperament test performed? ______yes ______no ______unsure
Result:
Describe your dog's behavior as a puppy:


Do you have any news about littermate behavior? (please describe)


Did you meet the parents? _____no _____yes, please describe their behavior:


Has this dog had other owners? ______no ______yes, how many? ____________
Why was the dog given up?_
_______________
At what age was your pet neutered/spayed? ___________________________
Why was this done?


Were there any behavior changes after neutering?

If your pet is "intact" has he/she ever been bred? ___yes ___no

Are you planning to breed? ____yes ___no ___unsure

If you have an intact female, when was her last heat? Did you notice behavioral changes while she was in heat?




Diet and Feeding


What do you feed your dog? (Please be specific, e.g. brand name)



Has your dog's appetite (increased, decreased, no change)? ____________________


How much do you feed? (please be specific) Meal Times ____________________


Who feeds the dog?
Location ______________________

What is your dog's favorite treat?



Daily Schedule - Typical 24 hr day

Please describe a typical 24-hour day in your dog's life:











How does the dog behave with familiar visitors?





How does the dog behave with unfamiliar visitors (children or adults)?


How do you exercise your dog?


Is the dog free in a fenced yard?
Is the dog tied outside?

Does the dog run free?

How do you play with your dog?

What toys does the dog have?

Is your dog housetrained? _____no _____yes How was the dog housetrained? At what age did s/he become reliable?



Does your dog ever eliminate in the house? __no __yes
urinate__ defecate _____


Where does your dog sleep at night (please be specific):



Have there been changes in your dog’s sleeping habits?

Where is your dog when alone in the house?


Where is your dog when you have guests?


How does your dog behave while you are leaving the house?


How does your dog behave when you return?




Obedience Training


What basic obedience training has your dog had? (Circle one)

None Trained at home
Started obedience classes but didn't finish
Graduated obedience class once
Graduated obedience class two or more levels
Private trainer Other ___________________

How old was the dog when obedience training started?

Who in the family is the primary trainer?


What per cent of the time does your dog obey the following commands, for each member of the family:


Family Member Sit Down Stay Come Walk on a loose lead Heel



Does your dog know any tricks? Please describe:



Have you exhibited your dog in breed shows?
_____yes _____no _____no, but I plan to
Has your dog had any hunting, herding, protection, attack or Schutzhund training?

Have you ever competed in any form of dog sport (obedience, agility, Schutzhund or other ring sports, herding)


Does your dog have any awards or titles? (Canine Good Citizen, obedience, agility, Schutzhund or other titles Please describe)



Does your dog jump up on you or others without permission? _____yes _____no

Does your dog paw at you or at others? _____yes _____no

Does your dog lick you? _____yes _____no

Does your dog mount people? _____yes _____no

If yes, whom does he or she mount?


Does your dog mount other animals or objects? _____yes _____no Please describe:


Does your dog ever bark at you? _____no _____yes When? Please describe:

Does your dog bark at other times? Please describe:



What is your dog's activity level in general (Circle one): Low Average High Excessive


Medical History


Is your dog on any medication now, for this or other problems?

Has your dog been on medication in the past?



PROBLEM BEHAVIORS:

Are there problems you are having with your dog? Please be specific and list them in the order of your priorities for training behavioral changes.



Is your dog’s behavior so difficult to live with that you would consider re-homing the dog if his/her behavior does not improve?



Have any family members already “given up” on the dog? Has anyone suggested that if the dog doesn’t change soon you’ll have to get rid of the dog? If so, who is it, and does he or she have the authority to make you give the dog up?



Have there been complaints made by neighbors (for excessive barking, wandering, chasing cars, growling at children?) To whom have they complained? (You? Landlord? The police?)




How frequently does the problem (or problems) occur (how many times daily, weekly or monthly):

a. Main Problem: Frequency:

b. Other Problem: Frequency:

c. Other Problem: Frequency:


Chronology Of The Behavior Problem

When did you first notice the main problem (age of dog)?



When did it first become a serious concern?


In what general circumstances does the dog misbehave?



Has this problem changed in frequency? (please describe)



Has this problem changed in intensity? (please describe)



Has this problem changed in other ways?




Describe several examples in detail:

1. Most recent incident: (Date: _________________)







2. Second to last incident: (Date: _________________)







3. Third to last incident: (Date: _________________)




Other significant incidents:











What have you done so far to try to correct the problem?





How do you discipline your dog for this and for other misbehavior?



Which of the following best describes your situation:

1. I am just curious about what you would suggest - problem is not serious.
2. I would like to change the problem, but it is not serious.
3. The problem is serious and I would like to change it, but if it remains unchanged that's all right.
4. The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog.
5. The problem is very serious and I would like to change it; if it remains unchanged I will give him/her up or have him or her euthanized.


Survey of aggressive behaviors: Please fill out this section even if you do not currently have any concerns about your dog’s behavior toward people. This information is essential for me to evaluate and consider before I decide whether the type of training plan I might offer is advisable or feasible.

How does your dog react under the circumstances described below? Please use one of these behavior descriptions (if applicable) to characterize your dog’s reactions.

GR - growl
SL - snarl/bare teeth
SB - snap/bite
NR - no reaction
NA - not applicable

How does your dog react when you:
1. pet dog
2. hug dog
3. kiss dog
4. lift dog
5. call off furniture
6. push/pull off furniture
7. approach on furniture
8. disturb while resting/sleeping
9. approach while eating
10. touch while eating
11. take dog food away
12. take human food away
13. take water dish away
14. take rawhide
15. take biscuit/cookie
16. take real bone
17. take toy/object
18. approach when dog has any object/toy/bone
19. verbally punish
20. physically punish
21. visual threat
22. speak to dog (normal tone)
23. stare at dog
24. bend over dog
25. push on shoulders or back
26. approach dog near spouse
27. enter room
28. leave room
29. reach toward dog
30. leash restraint
31. collar restraint
32. scruff restraint
33. put leash on/take off
34. put collar on/take off
35. bathe dog
36. towel dog
37. groom/brush dog
38. dog at groomer's
39. trim nails
40. leash/collar correction
41. response to "sit"
42. response to "down"
43. dog at veterinary clinic
44. unfamiliar adult enters house or yard
45. unfamiliar child enters house or yard
46. familiar adult enters house or yard
47. familiar child enters house or yard
48. response to toddlers/babies
49. dog in car at tollbooths, gas stations
50. unfam. adult approaches owner, dog on leash
51. unfam. child approaches owner, dog on leash
52. dog in house, sees people outside
53. response to other dogs, while on leash
54. response to other dogs, while not on leash

FOR AGGRESSION (TOWARDS PEOPLE)
Please answer yes or no to these characteristics of your dog's aggressive behavior:

______attacks are sudden and surprising
______episodes appear unprovoked
______the dog is abruptly docile after an episode
______the dog appears "sorry" afterwards
______the dog appears disoriented afterwards
______episodes are associated with a "glazed" or "absent" expression
______I can usually tell what will set off my dog
______the aggressive behavior is new and uncharacteristic


Has your dog bitten and broken a person’s skin? _____yes _____no

Number of bites that broke skin:____________________

Total number of bites (that did or did not break skin):__________________

Total number of episodes of aggression (growling, snapping, biting):______________

Describe typical episode (eg. does dog growl, lunge or bite, and in what circumstance?):





If the dog is in the above situation 10 times, in how many of those times is aggression seen (eg. all=100%, just one=10%, etc.)?




What parts of the body has the dog bitten and how severe were the injuries?







Who is/are the target(s) of aggression?



Did your dog bite as a puppy? _____yes _____no
If yes, please describe, including age:

How old was your dog the first time he/she growled at a person?


What was the circumstance?




How old was your dog the first time he/she snapped or bit at a person?


What was the circumstance?




Thank you for completing this form! I look forward to working with you.

Barbara Handelman

*This Canine Behavior Questionnaire and Aggression Screen have been expanded and modified from the original “Canine Behavioral History” form published by the Cornell University College of Veterinary Medicine. Animal Behavior Clinic, College of Veterinary Medicine, Cornell University Ithaca, NY 14853-6401. The Cornell University’s original form may be found at: http://www.vet.cornell.edu/abc/canine_history.htm