Canine Case Squad - New Client Intake Form Completed

Canine Behaviorists & Trainers-
Training & Insight into the Canine Mind
Canine Case Squad

For our new clients to Canine Case Squad we ask that you fill out the form below to the best of your ability/knowledge.
This will help us keep an up to date record of your dog and his/her behavior to allow us to assist you in the best and most effective way possible.

If you wish to print out a copy of this form and mail it in, please click here.

New Client Intake Form

Client

Name:

Last:

First:

Address:

Street:

City:

State:

Zip:

E-mail:

Telephone:

Fax: (optional)

Patient Info:

Name:

Breed:

Gender:

Male Female

Color:

Age:

Weight:

Date of Birth:

(if known)

Medical Information:

Animal Hospital:

Veterinarian:

Address:

Phone:

Referred By:

(if other than veterinarian)

Chief Complaint:

What is your biggest problem?

Owner History:

What type of work does everyone in the house do?

Does anyone in the house have a medical problem? If yes please specify.

Does anyone take prescription medication? If yes please list what medications.

Canine Medical History:

Is your dog spayed/neutered? (yes or no)

If yes, at what age was the procedure performed, reason for procedure, and finally any behavioral changes after procedure?

Provide dates for most recent vaccinations, if applicable:

Rabies:
Lyme Vaccine:
Canine Distemper:
Leptospirosis:

Please check all current medications:

Heartworm prevention:
Flea/Tick/Mite Control:
Antihistamine:
Anti-inflammatory:
Thyroid Hormone:
Antibiotic:
Other:

List conditions for which your dog has been treated, medication prescribed, and approximate dates:

Background Information:

Date (approximate) you acquired your dog:
Dogs age at that time:
Where did you get your dog:

Are you their first owner? If no, how many previous owners? Do you know why the dog was given up?

Which traits best describe your dog as a puppy?

What reason did you adopt this dog?

Have you owned pets before?

How did you select this dog over the other selections?

Describe the temperament of the dogs mother:

Describe the temperament of the dogs father:

Do you know the status of your dogs littermates?

Home Environment:

Describe your home:

Have you relocated since you have owned this dog? If yes approximate date?

List all members of your household; ages of children, hours per day away from home:

Please list all household pets in order of acquired:
please include type of pet, breed, genders, current age, and age acquired:

Describe your dogs relationship to other animals within the household:

Management:

Please describe a typical 24 hour day in the life of your dog:

Typically what percentage of the day does your dog spend indoors?

Do you have a fenced yard? (yes or no)

Does your dog run unsupervised outdoors? (yes or no)

Where does your dog sleep at night?

Where is your dogs favorite resting spot when you are at home?

Does your dog rest on your furniture?

Describe your dogs favorite toys:

Describe any interactive games that you play with your dog and note frequency:

Does your dog usually follow you from room to room? (yes or no)

Does your dog have free access to the house when your not at home? If no describe the confinement:

How does your dog behave when you prepare to leave home?

How does your dog behave when you return home?

List any items your dog chews or scratches:

What specific brand and type of food do you feed your dog?

How long have you been feeding your dog this diet?

Number of meals per day?

Do you leave food down for him/her to eat during the day (graze eating)? (yes or no)

Does your dog allow you to interrupt his eating? (yes or no)

Can anyone take the dogs food away? (yes or no)

Can anyone take away bone/treat? (yes or no)

Can anyone take away toys? (yes or no)

Which family members are responsible for feeding?

Location of bowl(s):

When does your dog eat "table food"?

Dogs favorite treats:

Describe your dogs reaction to thunderstorms:

Does your dog react to other noises? (yes or no)

Describe your dogs overall activity level:

Behavioral Details:

Please describe the main behavior problem:

Describe a typical episode:

Please answer the following questions for the main problem:

How do you correct your dog after he/she does something wrong?

When did you first notice the problem?

Describe the first incident:

Describe the most recent episode (include approximate date):

When did the problem become a serious concern? And why did you decide to seek the advise of a behaviorist?

Any household changes that occurred within 3 months of the onset of the problem?

What measures have you taken to correct the problem?

How do you generally discipline your dog? And your dogs typical response.

Please list any behavior problems or concerns you experience with your dog, please include frequency of problem/concern:

Aggression Survey: Please answer the following if your dog has bitten a person

Age of dog and circumstances surrounding first snap or bite:

Number of bites requiring medical attention:

Who were the targets of the aggression:

Body parts bitten:

Is aggression predictable? (yes or no)

Do the attacks appear provoked? (yes or no)

Is the dog docile afterward? (yes or no)

Does the dog appear disoriented afterward? (yes or no)

Does the dog appear sorry afterward? (yes or no)

Do you notice a glazed expression during the attack? (yes or no)

How does your dog behave towards visitors?

familiar visitors:

unfamiliar visitors:

children:

Complete the sentence:

My dog mounts:

It occurs mainly:

My dog mounts other animals or inanimate objects: (yes or no)

My dog jumps up on family members or others without permission: (yes or no)

My dog paws at family members: (yes or no)

My dog barks at family members: (yes or no)

My dog grooms itself excessively: (yes or no)

My dog urinates/defecates indoors in unacceptable locations: (yes or no)

How many weeks/months were required to train your dog?

Was a crate used? (yes or no)

Obedience Training:

Puppy Kindergarten: Age During Classes:

Group Obedience Classes:

Private Instruction (age, name of trainer):

List show, obedience, and other working titles:

Types of collar(s) used for training:

Aggression Screen: (N/R = No Reaction N/A= Not Applicable)

	Action	Reaction
1	Pet Dog
2	Hug Dog/Kiss Dog
3	Lift Dog
4	Approach Pet while Resting
5	Approach on Furniture
6	Call off furniture
7	Pull off furniture
8	Approach while eating
9	Touch while eating
10	Take dog food dish
11	Take water dish
12	Take human food or treat
13	Take rawhide or bone
14	Approach when has bone
15	Take toy or coveted object
16	Approach when dog is near his/her special person
17	Enter or leave room
18	Stare at dog
19	Speak to dog
20	Visually threaten the dog
21	Verbally punish
22	Physically punish
23	Give command to sit or down
24	Push into sit or down
25	Push on shoulder or rump
26	Restrain by leash
27	Restrain by collar
28	Put leash or collar on
29	Remove leash or collar
30	Reach for dog
31	Step over dog
32	Towel dry
33	Brush
34	Bathe
35	Trim nails
36	With veterinarian
37	With groomer
38	Unfamiliar adult/child enters house/yard
39	Unfamiliar dog enters house/yard
40	Familiar adult/child enters house/yard
41	On leash-person approaches
42	On leash-dog approaches
43	In house people/dog pass
44	In car-toll booth or gas station
45	Response to infant/toddler
46	Response to squirrel/cat

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