Owner name:      Animal name:

I. Please describe your animal:
Breed:      Age:      Sex: Male Female

Spayed/Neutered: Yes No      Age of Neutering:
Reason for neutering:
Were there any behavior changes after neutering?


II. Briefly describe the problem:


What was the age of the onset of the problem?
Is the problem currently getting worse or better? Worse Better
Frequency:
Is there anything that triggers the behavior?

Can your dog or cat be distracted from the behavior? Yes No
What do you do to distract them?


III. Training:
Have you ever been to a training class? Yes No      At what age?

Check what your pet can do:

Sit Stay

Down Heel

Come Stand

Fetch Tricks

IV. Family Members
Please list your family members and ages:

Who primarily takes care of the pet?
Any other care givers?

V. Please describe your pet's daily routine

Diet:
When fed:
How much:
What brand:
Any treats or table scraps:

Exercise:
Please describe your pet's exercise routine:

What time of day and for how long:

Leash Training:
Can your dog walk on a leash? Yes No
House environment:
Do you live in a house or apartment? House Apartment
What is the size and number of rooms?
How much access does your pet have?

Unobserved time:
How many hours is your pet alone in a day? What does he/she do?

Does he/she sleep when you are gone? Yes No

Litter boxes:
How many:      Covered or uncovered: Covered Uncovered
Type of litter:
Locations:

Sleeping:
Where do they sleep:

VI. Other Pets:
Please list your other pets, sex and ages:

How do they interact:


VI. Recent Changes:
Have there been any recent changes to your household?

Has anyone left? (pet or person)
Has anyone arrived? (pet or person)
Have you recently moved or had any remodeling done? Yes No

VIII. Medical Issues:
Does your pet have any previous health problems?

Medications:
Is your pet on any medications? Please list:
Heartworm Prevention: Yes No
When was the last rabies vaccine given?
Does your pet require a special diet? If yes, please list:


IX. Previous History
Any Previous Owners?
Where did you obtain this pet?
What age was the pet when you obtained it?

X. Behavior
Does your dog/cat?
Demand to be petted? Yes No
What do they do?
Check all that apply: