Private Client Questionnaire

This comprehensive questionnaire is for new clients who have already set up an appointment.
(privacy policy) (no-show/cancellation policy)

GENERAL INFORMATION

When is your appointment (date/time)?

Your Name		Email address

Daytime telephone number		Verify Email Address

Evening telephone number		Employer

Street address		Please contact me by email. Please contact me at my day phone. Please contact me at my evening phone. No Preference.

City, state, zip

Dog name(s)		Dog breed(s)

Dog Weight(s)

Dog age(s)		How long you've had this dog / these dogs


What behaviors or skills would you most like your dog to learn? What behaviors would you like to change? Please be specific and list them in order of your priorities. (You don't have to fill out the whole list - your top three would be fine.)


How did you hear about Ahimsa Dog Training?		Other Source

HOME ENVIRONMENT

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

Name	Age

Please list the animals, excluding the people, in the household.

Name	Species	Breed	Sex		Altered?		Age Obtained	Age Now
			F	M	Y	N
			F	M	Y	N
			F	M	Y	N
			F	M	Y	N
			F	M	Y	N
			F	M	Y	N

In all of the following questions, we will use the term “dog” instead of “dogs” because most people consult us about a single dog. If you have multiple dogs for which you are consulting us, answer all questions about each of them.

Describe your dog's relationship to the other animals (e.g. friendly, hostile, fearful).

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

What type of area do you live in?	What type of home do you live in?
Urban Suburban Rural	Apartment Condo Own House Rented House
Have you moved recently?	If so, how long ago?
Yes No
Has your household (people or animals) changed since acquiring your dog?	If yes, please describe.
Yes No

DOG'S BACKGROUND

Where did you get this dog?	Why did you decide to get a dog?
Animal Shelter Breeder - newspaper ad/flyer Breeder - referral Friend Pet Store Rescue Organization Stray Other:
How many guardians has this dog had, other than you?

If you are not the dog's first guardian (other than the breeder), why was this dog given up?

Why did you choose this dog / breed?

At what age was this dog spayed/neutered?	Were there any behavior changes after spaying/neutering?

Why was this done? Or why not?

If your pet is intact, has s/he ever been bred?

Are you planning to breed?	If you have an intact female, when was her last heat?

If you have an intact female, did you notice any changes while she was last in heat?

DIET AND DAILY ROUTINE

What is your dog's energy level, in general: What energy? Low Medium High Excessive
What is your dog's appetite, in general: Finicky Somewhat Finicky Moderate High Chow Hound
What do you feed your dog? Please be specific, e.g. brand name:
Has your dog's appetite changed?	How much do you feed? (Please be specific.
Increase Decrease No Change
	Who feeds the dog?
When are your dog's meal times?
	Where is your dog fed?

What is your dog's favorite treat?

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

How do you exercise your dog and how often?	Do you have a yard? YES NO

How do you play with your dog? What toys does your dog have?

Check all that apply when your dog is alone: Dog is free in a physically fenced yard. Dog is free in an "invisibly" fenced yard. Dog is in an outdoor kennel. Dog is free inside the house. Dog is crated inside the house. Dog is tied outside.	Is your dog housetrained? YES NO. If yes, how reliable is s/he and at what age did s/he become reliable?


Where does your dog sleep at night? (Please be specific)	Have there been any 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 home?

How does your dog behave when you return home?

Is your dog accustomed to a muzzle? yes no Muzzle comments (dog's experience with muzzle, type of muzzle you use, why or why not accustomed to muzzle):

TRAINING EXPERIENCE

What basic manners training has your dog had?
None Trained at home Started a training class but didn't finish Graduated basic training class Graduated two or more levels of training class Private trainer Other: Please list the trainer(s) or behaviorist(s) you have worked with for this dog:
If your dog has had prior training, rate how much you have used the following methods to teach your dog a new behavior. Use a scale from 0 to 5, with 0 meaning, "I have never used this method" and 5 meaning, "I have used this method a lot."
Dog is placed into position manually. Dog is lured into position. Dog is shaped into position using a clicker or verbal marker like "yes!" Behavior is captured using a clicker or verbal marker. Dog is punished with a leash correction for not obeying a command. Dog is punished using an electric collar for not obeying a command. Dog is verbally punished for not obeying a command. Dog is ignored for not responding to a cue.

How old was the dog when basic manners training started?				Who in the family is the primary trainer?

For each family member, state the percent of the time that your dog will respond to each of the following cues. (LLW stands for loose leash walking).
Name	Sit	Down	Stay	Come	Loose Leash Walking	Heel




Does your dog know any tricks? Please describe one or two of them.

Has your dog had any hunting, herding, protection attack, or Schutzhund training? YES NO If yes, describe.

Have you ever competed in any form of dog sport? YES NO If yes, describe.

DOG'S BEHAVIOR

How does the dog act with familiar visitors? (children or adults)

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

Does your dog mount people or objects? YES NO If yes, what or whom does s/he mount?

Does your dog ever bark at you? YES NO If yes, describe.

Does your dog bark at other times? YES NO If yes, describe.

Does your dog jump on people without permission?	Does your dog paw at you or at others?
YES NO	YES NO

DOG'S MEDICAL HISTORY

Is your dog on any medication now, for any reason? YES NO

Has your dog been on medication in the past? YES NO

When was your most recent visit to the vet?	Who is the dog's veterinarian?

If this problem may be physical in nature (incontinence, sudden aggression, etc.), has your vet already done an examination to rule out medical causes?
YES NO. If so, list tests done below

PROBLEM BEHAVIORS

Are there behaviors that you would rather your dog didn't do? Please be specific and list them in the order of your priorities for training behavioral changes. If you have more than five major problems, just use the last box for more than one problem.
Problem 1:

Problem 2:

Problem 3:

Problem 4:

Problem 5:

Choose the following option that best describes your situation.
I am just curious about what you would suggest - problem is not serious. I would like to change the problem, but it is not serious. The problem is serious and I would like to change it, but if it remains unchanged that's all right. The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog. 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 put to sleep.
Have any family members already “given up” on the dog? YES NO. Has anyone suggested that if the dog doesn’t change soon you’ll have to get rid of the dog? YES NO. 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? YES NO.
If so, to whom have they complained? (You? Landlord? The police?)

How frequently does the problem occur?
Problem 1:	several times per day	daily	weekly	monthly	only a few times per year
Problem 2:	several times per day	daily	weekly	monthly	only a few times per year
Problem 3:	several times per day	daily	weekly	monthly	only a few times per year
Problem 4:	several times per day	daily	weekly	monthly	only a few times per year
Problem 5:	several times per day	daily	weekly	monthly	only a few times per year
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? YES NO If yes, please describe below.

Has this problem changed in intensity? YES NO If yes, please describe below.

Describe any other ways this behavior problem has changed.

Describe several examples in detail, starting with the most recent incidents:
Most recent incident: Date:

Date:

Date:

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



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 the worst of your dog’s reactions. If you do not feel comfortable doing some of these things, by all means, don't do them! Some of the things on this list are not recommended for any dog. NA - not applicable NR - no negative reaction BR - bark or whine GR - growl SL - snarl/bare teeth SB - snap/bite

Pet dog			NA NR BW GR SL SB
Hug dog			NA NR BW GR SL SB
Kiss dog			NA NR BW GR SL SB

Lift dog			NA NR BW GR SL SB
Call off furniture			NA NR BW GR SL SB
Push/pull off furniture			NA NR BW GR SL SB

Approach on furniture			NA NR BW GR SL SB
Disturb while resting/sleeping			NA NR BW GR SL SB
Touch while eating			NA NR BW GR SL SB

Take dog food away			NA NR BW GR SL SB
Take 'human' food away			NA NR BW GR SL SB
Take water dish away			NA NR BW GR SL SB

Take rawhide or plastic bone			NA NR BW GR SL SB
Take biscuit / cookie			NA NR BW GR SL SB
Take real bone			NA NR BW GR SL SB

Take toy			NA NR BW GR SL SB
Approach when dog has any object/toy/bone			NA NR BW GR SL SB
Verbally punish			NA NR BW GR SL SB

Physically punish			NA NR BW GR SL SB
Leash correction			NA NR BW GR SL SB
Visual threat			NA NR BW GR SL SB

Speak to dog (normal tone)			NA NR BW GR SL SB
Stare at dog			NA NR BW GR SL SB
Bend over dog			NA NR BW GR SL SB

Push on shoulders or back			NA NR BW GR SL SB
Approach dog near spouse			NA NR BW GR SL SB
Enter room			NA NR BW GR SL SB

Leave room			NA NR BW GR SL SB
Reach toward dog			NA NR BW GR SL SB
Leash restraint			NA NR BW GR SL SB

Collar restraint			NA NR BW GR SL SB
Scruff restraint			NA NR BW GR SL SB
Put leash or collar on / take off			NA NR BW GR SL SB

Bathe dog			NA NR BW GR SL SB
Groom/brush dog			NA NR BW GR SL SB
Dog at groomers			NA NR BW GR SL SB

Trim nails			NA NR BW GR SL SB
Dog at veterinary clinic			NA NR BW GR SL SB
Unfamiliar adult enters house or yard			NA NR BW GR SL SB

Unfamiliar child enters house or yard			NA NR BW GR SL SB
Familiar adult enters house or yard			NA NR BW GR SL SB
Familiar child enters house or yard			NA NR BW GR SL SB

Response to toddlers/babies			NA NR BW GR SL SB
Dog in car at gas stations, drive-thru windows			NA NR BW GR SL SB
Unfamiliar adult approaches guardian, dog on leash			NA NR BW GR SL SB

Unfamiliar child approaches guardian, dog on leash			NA NR BW GR SL SB
Unfamiliar dog approaches guardian, dog on leash			NA NR BW GR SL SB
Dog in house, sees people outside			NA NR BW GR SL SB
Response to other dogs, while not on leash			NA NR BW GR SL SB

If you'd like to comment on any of the above items, do so below.

Has your dog ever acted aggressively toward a human? YES NO If No, click here to skip to the bottom. Otherwise, answer the questions below.



Which of the following describes an aggressive episode for your dog? 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
Total number of bites (that did or did not break skin)
Number of bites that have broken human skin
Total number of episodes of aggression (growling, snapping, biting)
Describe typical episode (i.e. 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?
What parts of the body has the dog bitten and how severe were the injuries?

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

Describe the biting your dog did as a puppy (including play)

How old was your dog the first time he/she growled at a person (not in play)? Describe the circumstance.

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


Any other questions or comments for us? Please write them here!

Thank you for taking the time to complete this form. We look forward to working with you. Now go get yourself some chocolate to reward yourself!

*This Canine Behavior Questionnaire and Aggression Screen have been expanded and modified by Ahimsa Dog Training, Seattle 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