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Behaviour Modification Form
Behaviour Modification Form
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2018-08-31T22:01:05-08:00
Behaviour Modification Form
Name
*
First
Last
Address
*
City
*
Province
*
BC
Postal Code
*
Phone Number
*
Email
*
Your Dog's Name
*
Breed or Mix
*
Coat Colour(s)
*
Gender
*
Male
Female
Age
*
Weight
*
Sterilization
*
Neutered
Spayed
Intact
How did you hear about mutt & moggy Training & Pet Care?
*
Website
Google search
Email newsletter
Facebook
Twitter
Instagram
Business card
Veterinarian
Friend or family member
Other
We value referrals! If you were referred to us, please let us know so that we can thank them!
Who is your dog's veterinarian?
*
When was your dog's last physical examination at the veterinarian?
*
Does your dog have any known medical issues?
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Yes
No
If YES, what are your dog's known medical issues?
Please list all medications and dosages that your dog is currently on.
Vaccination Status
*
My dog is up to date on all core vaccines.
My dog has a positive titre test not older than one year.
My dog is up to date on the rabies vaccine.
Where did you obtain your dog? Please include the name of the rescue, shelter, or breeder, if applicable.
*
Why did you obtain your dog (companionship, guard dog, sport competition, playmate for current dog, etc.)?
*
When did you obtain your dog?
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If you obtained your dog as a puppy, how old was s/he when you brought her/him home?
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Has your dog had any prior training?
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Yes, group puppy class
Yes, group adult class
Yes, private lessons
Yes, board & train
Informal training at home
No, but we're ready to learn
Who was the trainer?
*
Is your dog crate trained?
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Yes, my dog LOVES the crate!
Yes, my dog tolerates the crate.
Yes, but I no longer crate my dog.
Would like to crate train, but I'm not sure how to get started
No, prefer not to use a crate.
No, my dog HATES the crate!
What training tools do you currently use with your dog? Check all that apply.
*
Flat collar
Martingale collar
Choke chain
Prong collar
Electric collar (shock / stim / vibration)
Head halter (Gentle Leader / Halti)
Body harness (Easy Walk / Freedom / Balance)
Other - Please list below
Other training tool - please list.
Do you walk your dog using a Flexi or retractable leash?
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Yes
Sometimes
No
Does your dog receive daily walks of at least 45 minutes per day?
*
Yes
No
If your dog has food allergies, please list them here (or input n/a).
*
What brand(s) of food do you feed your dog?
*
Feeding schedule?
*
Free fed (food always available)
Scheduled mealtimes (eats everything)
Scheduled mealtimes (grazes)
Food drive?
*
High
Medium
Low
Depends
Not sure
No interest in food / treats
Toy drive (playing fetch or tug with people)?
*
High
Medium
Low
Depends
Not sure
No interest in toys
What behaviours are you looking for help with?
*
Barking
Chewing
Digging
Fear & phobias
Reactivity & aggression - with dogs
Reactivity & aggression - with people
Remedial socialization for adult dogs
Resource guarding - with dogs
Resource guarding - with people
Separation anxiety
If your dog's behaviour is not listed above, please describe it here in detail.
How long have you been dealing with the issue(s)?
*
What behaviour modification have you done to date, if any?
Is your dog friendly with unfamiliar people?
*
Seems to love just about everyone
Good with unfamiliar women
Good with unfamiliar men
Good with unfamiliar children
Selective with all people
Tolerant (okay in their presence, but doesn't like to be touched by strangers)
Scared, avoids strangers
Aggressive (growls, barks, lunges, etc.)
Not sure
Is your dog friendly with unfamiliar dogs?
*
Seems to love just about every dog
Good with big dogs
Good with small dogs
Good when off-leash only
Selective with all dogs
Tolerant (okay in their presence, but doesn't like to be sniffed or interact)
Scared, avoids other dogs
Aggressive (growls, barks, lunges, etc.)
Not sure
Has your dog ever bitten a person (not including puppy nipping or play mouthing)?
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No
Not to my knowledge
I'm not sure if it was play or aggressive
My dog has growled but never bitten
Yes, but the bite left no mark
Yes, the bite bruised the skin
Yes, the bite left a shallow puncture
Yes, the bite left a deep puncture
Yes, the bite tore the skin
Yes, the bite left multiple punctures
Yes, my dog has bitten multiple times
If YES, please describe the injuries inflicted in detail and explain the circumstances of the bite(s).
Is there anything else you would like us to know?
What days / time frames would work best for you to schedule a behaviour modification initial consult?
*
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