Dog Behavior Questionnaire

To make the most of your initial assessment, it is beneficial to know details about your dog(s) history regarding problem behaviors prior to our visit. This way, more time can be spent addressing your primary concerns. Completing this questionnaire is the first step to restoring calm to your house and rediscovering the joy of owning a dog. Once we receive this form, we will contact you to set up an appointment.
Dog Behavior Questionnaire:
Owner's Full Name *

First Name Last Name
Other Owner's Full Name

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone *

Area Code Phone Number
Other Cell Phone

Area Code Phone Number
E-mail *
example@example.com
Other E-mail
example@example.com
How did you hear about us? *
Who can we thank for your referral?
Name of clinic or person who referred you
Household Members
Adults and children (please include age of children)
Dog Information
Dog Name
Name
Breed *
Age *
Gender
Weight
Spay/Neuter? (y/n)
Where or from whom did you obtained your pet?
Breeder/shelter/previous home
How old was your dog when you got him/her?
How long have you had this dog?
Additional pets in the household
Name/Age/Species/Breed/Gender/Spay, Neuter
The Home Environment
Where does your dog sleep at night?
location/loose or in a crate
Type of food you feed your dog
Brand/Dry or Canned
How often is your dog fed?

Once daily Twice daily Three times daily My dog is not on a feeding schedule, food is available all the time
What type of eater is your dog?
picky, voracious, fast
Describe how pets get along with each other
Describe what your dog's response is to visitors in the home
What does your dog do to greet visitors at the front door
Has there been any changes to the dog's home or surrounding environment recently, such as: construction, move, death, birth?
Please describe if your dog has reacted to these changes
Exercise
Would you describe your dog as high, medium, or low energy?
How often is your dog walked off the property?
Average number of minutes/hours of walking exercise per day?
Are walks off the property consistent?
What type of other exercise or play does your dog get?
ball play, running, dog park, other
Average length of play
Training History
Has your dog had obedience training

Private Training Puppy Classes Other Group Classes I trained my dog myself Sent away to "boot camp"
Age of dog during training? Where did you attend training?
age of dog and name of facility/trainer
Type of training collar used (past and present, check all that apply)

Flat buckle collar Choke collar or prong collar Shock/vibration/electrical stimulation collar (including shock containment systems and bark collars) Harness
Type of training that was most successful
Type of training that was least successful
i.e. only listens when I have a treat, better when at home, doesn't listen around other dogs
What skills can your dog perform reliably in most situations

sit lay down come when called drop it/leave it walks nicely on leash settle on a mat/stay off (getting off furniture or people)
How would you describe the type of training that your dog has received (check all that apply)

Reward based (food) Reward based (praise) Lure based Correction/Punishment based Dominance based Leadership based
Reinforcement
Please make a list of your dog's favorite things that we may use to reinforce good behavior
favorite treats, favorite toy, affection, belly-rubs, etc.
Punishment
In what ways have you disciplined/corrected your dog for unwanted behaviors (check all that apply)

Physical reprimand (spanking, flicking, smacking) Noise (shaker cans, sirens) Water sprayer Verbal reprimand Muzzle grab Pinning to the ground Booby traps/repellants Remote operated shock collar Rubbing nose in messes or showing them a mess they made Leash correction Ask for a different response I don't Time out
What punishment was most effective and why?
Does any punishment make the problem worse? Describe
Is your dog crate trained? If so, do they like it?
Body Handling
Does your dog respond negatively to any of the following?

Nail trim Bathing Grooming Brushing Ear cleaning Being lifted
Medical Screen
Appetite

Normal Decreased Eats fast
Does your pet have any arthritis or other painful conditions?
Does your pet drink or urinate excessively?
Stools

Normal Constipation Diarrhea
Any other medical problems
Is your pet on any medications?
Has your pet had any laboratory tests?
Name of Veterinarian/Vet Clinic
Reactivity
Do any of the options below cause your dog to become aggressive, anxious, or fearful? check all that apply

Familiar dogs on property Familiar dogs off property Unfamiliar dogs on property Unfamiliar dogs off property Unfamiliar person outside on property Unfamiliar person off property Unfamiliar person approaches/try to pet Unfamiliar person arriving indoors On a walk, sees cat, squirrel, or wild animal Car rides Thunderstorms/fireworks Other loud noises
Describe checkmarks above
Separation Anxiety Screen
When you leave your home is your dog confined or crated?
How long is your dog left alone on an average day?
How does your dog react when you prepare to leave?
How does your dog react at the time of departure?
What is the dogs reaction to homecomings?
Have you ever left the dog alone in the car? If yes, how does he/she react?

Does your dog regularly (at least weekly) engage in any of the following behaviors? Please differentiate if the behavior occurs in your (human) presence or your absence and indicate the frequency (number of times it occurs per week).

	In my presence (times per week)	In my absence (times per week)
Excessive barking whining
House soiling (urine/feces)
Destructive chewing
Self licking/chewing

Fearfulness/Anxiety
Please describe any fearful behaviors, body language or vocalizations your dog may demonstrate that appear to be a problem to your dog and/or to you, such as: attempts to run away, hide.
Are there objects or environments in which your dog is fearful or afraid?
Please list all triggers of a fear response
Aggression Screen
When was the most recent attempt to bite or threaten? Describe in detail.
Situations causing aggression

Petting/handling/restraint Eating food/treats Chewing toys/stolen objects Waking up
Is aggression the primary reason for our visit?
What is the potential for injury

None Minimal Moderate Severe
Is the situation serious enough that you'd be unable to keep your pet if the issue isn't improved?
Is your dog ever aggressive to members of your family? Describe
Is your dog ever aggressive to visitors in your home? Describe
Is there a particular type of person/location/situation where aggression is most likely to occur? Describe
Has your dog ever bitten hard enough to break skin? Describe
When your dog threatens or attempts to bite, how do you handle the situation and what is the dogs reaction?
After your dog has bitten how do you handle the situation and what is the dogs reaction?
How would you describe your dogs attitude at the time of aggression?
Bold/protective/outgoing/fearful
Miscellaneous
Repetitive/compulsive/unusual activity

tail chasing sucking fly chasing light chasing
Please describe:
Principal Complaint
What is the primary problem?
Aggression/destructive/barking/etc
When did the problem begin? What age was your dog when it started?
What do you think caused the problem?
Describe the problem, beginning with the most recent incident.
Describe the first incident.
What has been done so far to correct the problem? What was the dogs response?
Any social/household dynamics that may impact consistency in training, or differences in goals
LIABILITY WAIVER & POLICIES

Liability Waiver: Julie Schmitt and Out N’ About Dog Training, LLC will endeavor to create as safe an environment as possible for the training of my dog and will offer only sound, safe, and responsible training and training instructions. However, I recognize that Out N’ About Dog Training, LLC is not responsible for any unintentional errors, omissions, or incorrect assertions. I understand that the recommendation of any other product or service is not a guarantee of my satisfaction with that product or service. Further, I am and will remain responsible for the actions of my dog at all times and I hereby agree to indemnify and hold harmless Julie Schmitt and Out N’ About Dog Training, LLC of any and all claims of injury, expense, costs, or damages caused by the actions of my dog while under Julie Schmitt’s instruction or control and under my own care as a result of following training instructions. I have been told by Julie Schmitt, of Out N’ About Dog training, LLC, and understand the inherent risks in owning a dog, including but not limited to the risk of dog bites to myself or others.

Due to the variable and unpredictable nature of behavior, Julie Schmitt and Out N' About Dog training, LLC make no guarantee, express or implied, that their dog training services will improve an individual dog’s behavior. However, they will work toward ensuring satisfaction of services.

I, the dog owner, understand that training never has an end and that my dog needs my guidance for the remainder of his or her life. I also understand that if I stop practicing what I have learned, my dog WILL regress back to old behaviors.
Signature *

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Payment Policy: Client/Owner agrees to payment in full at time of service. Current pricing can be found on www.OutNAboutDogTraining.com. There are no refunds on services. Unused sessions expire 60 days from date of purchase.
Initial *

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Cancellation policy: Lessons may be cancelled and rescheduled with a 48 hour notice. After that time, client will be charged full price for the lesson missed.
Initial *

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Julie Schmitt - Out N' About Dog Training, LLC

I only use non-aggressive, force and fear free training methods based upon the science of behavior and behavior change. These methods are recommended by educated Veterinarians and Veterinary Behaviorists, American Animal Hospital Association, American Veterinary Medical Association, American Veterinary Society of Animal Behavior, and modern dog trainers like myself.

As such, I do not use choke, prong, shock or bark collars or an electric fence when I am training dogs. Furthermore, I do not condone the use of dominance based training of dogs, including knee jabs, scruff shakes, side kicks, alpha rolls, spray bottles or any other forceful, painful or aggressive training methods. Shock devices and other forms of aversive ‘training’ tools are never recommended and those using them are encouraged to discontinue their use before effective behavior change and modification can take place.

Client/Owner agrees to use training and management to prevent their dog(s) from biting or attacking another person, adult or child and other animals. Client/Owner understands NO DOGS should ever be left alone with a child. Full Awake Adult Supervision is required for children and dogs.

Understand that once a dog has bitten, it must ALWAYS be supervised.

Understand that no dog can be 100% cured of aggression.

Client/Owner understands that if aversive training devices or techniques are used during our contracted working relationship, no further sessions will be scheduled.

Client/Owner agrees to allow photos and videos of their training process on various social media pages. The dog's first name will only be used as identification.

This contract is validated by the signature below in total and as approval for future services without additional written authorization.
Signature *

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Dog Behavior Questionnaire:

Household Members

Dog Information

The Home Environment

Exercise

Training History

Reinforcement

Punishment

Body Handling

Medical Screen

Reactivity

Separation Anxiety Screen

Fearfulness/Anxiety

Aggression Screen

Miscellaneous

Principal Complaint