Obtaining the following information prior to consultation allows more time to be dedicated to assessment and treatment. Please ensure this document, as well as the veterinary referral form are completed and signed so your assessment can proceed.
Please fill in each question as accurately and honestly as possible, there are no right or wrong answers. Please email your completed questionnaire back, or send via post (please contact us for an address). If a section is not relevant to you please move onto the relevant section.
Optional answers: please make it clear which you have picked by either deleting the irrelevant option or making your option BOLD. Many thanks.
Section One: Client InformationName:
Address:
Phone: Home: Mobile:
Work: Email:
Veterinarians name and practise:
Practise address:
Phone: Fax:
Section Two: Dog’s Information
Name: / D.O.B: / Age:Breed: / Colour: / Age Obtained:
Sex: M/F / Neutered: Y/N / Age Neutered:
Reason for Neutering:
Any noted changes after neutering?
Section Three: Medical Information
Date of last vet visit: / Reason:Any current or previous medical problems? Y/N Please state:
Current Medication? Y/N (Describe, name, dosage, duration)
Does the dog have any allergies? Y/N Please state:
Does the dog have normal eating and bowel movement? Y/N Description:
Does the dog: / Drink Excessively: Y/ N / Urinate Excessively: Y/N
Appetite: (circle) Normal Decreased Picky Increased Eats Fast
Stools: (circle) Normal Constipation Less frequent More frequent Soft/diarrhoea
Urine: (circle) Normal Infrequent More frequent More volume
If your dog has had any tests (x-rays, blood, urine, faeces etc) please indicate any findings:
Section Four: Social History
Where did you get your dog?Breeder? (if applicable)
Why did you obtain your dog? If applicable why this breed?
Has your dog had previous owners? Y/N if Y how many?
If yes, the reason for re-homing if known:
If known, did parents or siblings engage in similar behaviours, or have any other behavioural problems?
Briefly describe your dog’s personality(e.g. confident, timid etc)
Section Five: Problem Behaviour
What is the problem behaviour? Please describe it as accurately as possible.
When did you first notice this problem? (description)
How old was the dog when the problem started?
Describe the severity of the problem: (circle) Mild Moderate Severe
Have you considered euthanasia? Y/N
How long does each incidence last?
What is the frequency of the problem?
Has there been a change in frequency or severity?
Y/N Description:
What do you think caused the problem?
Any changes in the home or dog’s health that co-insides with the start of the problem?
How do you and other family members react to the problem?
What have you tried so far to try and correct the problem and how did the dog response? Please list:
i.e. ‘put the dog outside’ – made him bark more
Any techniques that have been successful?
Any techniques that have made the problems worse?
Are there any specific conditions that seem to trigger the behaviour?
Can you interrupt your dog when engaging in the behaviour?
What is your dog’s reaction when you try to stop the behaviour?
Please describe in detail the last time the behaviour occurred:
List any drugs, including dosage tried so far and the dog’s response to it:
List any other dietary treatments, supplements, or remedies and the dog’s response:
Section Six: Home Environment
Does your dog have a favoured sleeping place? Where?Have you ever used a crate for confinement? Y/N if yes, description and location
Dog’s reaction to crate:
Is the crate still used? Y/N If no why did you stop?
Is your dog restricted from any areas of your home? Where?
What do you feed your dog and how often? / Do you give treats to your dog and in what situation?
What is your dog’s appetite? Finicky somewhat finicky, moderate, high, eats anything
Has your dog’s appetite changed?
Who feeds the dog? / When are meal times? / Where is your dog fed?
List all people living in the household, including sex and ages of children:
List all pets, include species, age, breed, neutered and sex:
Where these pets in the home when the dog was acquired?
Describe interaction with other pets:
Do any of your other pets have any issues that need to be listed?
Describe interaction with family members:
How does your dog react to strangers?
How does your dog react to going to the vets, and being examined?
Section Seven: Daily Activities and Routines
Briefly describe a typical day, from time up to time asleep:
Who exercises / plays with the dog?
Is your dog walked on /off lead?
Type of exercise / play: (be specific)
How often, how long: (be specific)
Does your dog play with other animals? How long, where?
Favourite game: / Favourite toy:
Question Eight: Survey
Number of times groomed weekly: / By who?
Describe your dog’s reaction to the following: choose one of these options:
NA – not applicable
NR - no negative reaction
BR – bark or whine
GR – growl
SL – snarl/bare teeth
SB – snap/bite
Handling Information
Petting: NA NR BR GR SL SB / Brushing: NA NR BR GR SL SB
Hugging/kissing: NA NR BR GR SL SB / Bathing: NA NR BR GR SL SB
Rubbing stomach: NA NR BR GR SL SB / Nail trimming: NA NR BR GR SL SB
Rolling over: NA NR BR GR SL SB / Ear cleaning: NA NR BR GR SL SB
Grabbing collar: NA NR BR GR SL SB / Brushing teeth: NA NR BR GR SL SB
Giving pills: NA NR BR GR SL SB / Giving liquid medication: NA NR BR GR SL SB
General Information
Lift dog : NA NR BR GR SL SB / Call off of furniture: NA NR BR GR SL SB
Push/pull off furniture: NA NR BR GR SL SB / Approach on furniture: NA NR BR GR SL SB
Disturb while resting/sleeping: NA NR BR GR SL SB / Touch while eating: NA NR BR GR SL SB
Take dog food away: NA NR BR GR SL SB / Take ‘human’ food away: NA NR BR GR SL SB
Take water dish away: NA NR BR GR SL SB / Take rawhide or plastic bone: NA NR BR GR SL SB
Take toy: NA NR BR GR SL SB / Approach when has any object: NA NR BR GR SL SB
Verbally punish: NA NR BR GR SL SB / Physically punish: NA NR BR GR SL SB
Leash correction: NA NR BR GR SL SB / Visual threat: NA NR BR GR SL SB
Speak to (normal voice): NA NR BR GR SL SB / Stare at dog: NA NR BR GR SL SB
Bend over dog: NA NR BR GR SL SB / Push on shoulders/neck: NA NR BR GR SL SB
Approach dog near spouse: NA NR BR GR SL SB / Enter room: NA NR BR GR SL SB
Leave room: NA NR BR GR SL SB / Reach toward dog: NA NR BR GR SL SB
Leash restraint: NA NR BR GR SL SB / Collar restraint: NA NR BR GR SL SB
Scruff restraint: NA NR BR GR SL SB / Dog at vets: NA NR BR GR SL SB
Bathe dog: NA NR BR GR SL SB / Unfamiliar adult enters home: NA NR BR GR SL SB
Dog at groomers: NA NR BR GR SL SB / Trim nails: NA NR BR GR SL SB
Unfamiliar child enters home/garden: NA NR BR GR SL SB / Familiar adult enters home: NA NR BR GR SL SB
Familiar child enters home: NA NR BR GR SL SB / Response to toddlers/babies: NA NR BR GR SL SB
Dog in car at garage/drive through: NA NR BR GR SL SB / Unfamiliar adult approaches handler while on lead: NA NR BR GR SL SB
Unfamiliar child approaches handler while on lead : NA NR BR GR SL SB / Unfamiliar dog approaches on lead: NA NR BR GR SL SB
Dog in house while seeing dog outside: NA NR BR GR SL SB / Response to other dog while off lead: NA NR BR GR SL SB
If you would like to add additional comments to the above please do so here:
Section Nine: Training Information
Has your dog had any training? Y/N / Class / Private instructor / Trained at home
Please describe the training classes (if applicable):
What types of collar/s have been used, and how did your dog react? (e.g. remote collar – shock, citrus, head collar, body harness)
Description of training (please circle): Reward based pack Leadership Corrective Clicker Treats Verbal praise Other
Have you used any of the following?
Physical: Y/N / Dog’s reaction:Noise (shaker etc): Y/N / Dog’s reaction:
Verbal: Y/N / Dog’s reaction:
Water: Y/N / Dog’s reaction:
Scruff: Y/N
Pinning: Y/N
Grab Muzzle: Y/N / Dog’s reaction:
Dog’s reaction:
Dog’s reaction:
Time out: Y/N / Dog’s reaction:
Does anything make the problem worse?
How do you reward your dog?
What is your dog’s favourite reward?
If your dog could have anything as a reward, what would be the favourite? List top five:
Does your dog respond differently to any techniques from different family members?
Anything else used that isn’t listed and dogs reaction:
Most successful training:
Least successful training:
What is the dog’s learning ability:
Is your dog receiving any on-going training: Y / N Description:
Family members with most control:
Family members with least control:
Can your dog do any of the following, please state how well from poor through to excellent, and places where can do (i.e home, garden, on walks)
Sit: / Down: / Heel:
Stay: / Wait: / Leave:
Come: / Drop: / Fetch:
Loose lead walking:
Can your dog do any tricks? Please describe:
Can your dog settle on command? Y/N Description:
Section Ten: Toilet Habits
Where is the main location for your dog to eliminate?
How many times a day does your dog: Urinate Defecate
Is your dog completely housetrained? Y/N If yes proceed to next section.
Does your dog ever eliminate outdoors? Y/N
Do you accompany your dog to eliminate? Y/N
What is your preferred area for your dog to eliminate?
What do you do when your dog eliminates in the wrong place?
What do you do when your dog eliminates in the right place?
How often does your dog soil in the house?
When is your dog most likely to soil the house?
Does your dog signal the need to eliminate? Y/N Description
By what means does your dog soil the house? (circle) urinate defecate both
What locations indoors is your dog most likely to soil?
Does your dog soil when family members are home? Y/N description:
Does your dog soil while you are watching? Y/N description:
What do you do when you find urine or faeces in an improper place?
Does your dog urine mark? Y/N describe:
Does your dog ever eliminate in a location that he/she has been sleeping? Y/N
Does your dog ever leak / dribble urine? Y/N
Do you ever confine your dog to a crate? Y/N if yes does your dog ever eliminate in the crate? Y/N
Uncontrollable urination when excited? Y?N / Uncontrollable urination when frightened? Y/N
Does your dog leak urine while: (circle) sleeping walking approached by owner’s approached by stranger approached by other dog’s
Section Eleven: Separation Information
How long is your dog left on average each day?
How does your dog act as you prepare to leave the house?
What time of the day is you dog left?
When you go out is your dog crated? Y/N. If no, please indicate what area’s are restricted:
Has your dog ever been left with a friend/relative, kennels or veterinary surgery? Y/N
If yes to the above please describe your dog’s reaction:
Is the dog ever left alone outdoors? Y/N / How often? / How long on average?
Reaction to being left outdoors:
Where is the dog left when left outdoors?
Does your dog exhibit any behaviour problems when left alone? Y/N
If no, proceed to reaction information
Description of problem behaviour when left alone: (please list problems)How does your dog react at the time of you departing?
Does the behaviour differ on the time of day or the amount of time the dog is left, or on who leaves it last?
How does the dog react to you arriving home?
Have you ever left your dog alone in the car? Y/N Describe your dog’s reaction:
Section Twelve: Reaction Information
Please indicate how your dog reacts to each of the following
1 = calm 2= excited 3 = ambivalent 4 = fearful 5 = friendly 6 = aggressive
Familiar dogs on property:
/Familiar dogs off property:
New dog’s on property:
/New dog’s off property:
Strangers outside on property:
/Strangers off property:
Strangers arriving indoors:
/Car rides:
Thunder storms/ fireworks:
/Other loud noises:
Dog’s on lead:
/Dog’s off lead:
Other dogs when on lead:
/Other animals:
Section Thirteen: Aggression Information
Does or has your dog ever displayed aggression, directed at anything? Y/N
If no move on to section Fourteen
What has your dog displayed?
/Threatening displays? Y/N
/Growling? Y/N
/Bite attempts? Y/N
/Bite’s? Y/N
If your dog has bitten, please describe the injury on each occasion that was inflicted:
When was the most recent display of aggression?
Situations causing aggression:
Petting / handling/ restraint: (circle) growled attempted to bite, bitten, no aggression
If any, description:Chewing toys / stolen objects: growled, attempted to bite, bitten, no aggression
If any, description:Waking up: growled, attempted to bite, bitten no aggression
If any, description:If there has been no aggression or issues have been resolved, then you can move onto section fourteen
Is aggression the main reason you are seeking help? Y/N
What is the potential for injury: (circle) none/preventable, minimal, moderate severe
Is the problem serious enough that you may not be able to keep your pet if it doesn’t improve? Y/N
Is your dog ever aggressive to any member’s of your immediate family? Y/N If yes please give details:Is your dog ever aggressive towards visitors to your home? Y/N if yes answer the following: Were the people: (circle) strangers, known, both
Is your dog aggressive when off the property? Y/N: to strangers, known, both
Is there a particular type of person that your dog is aggressive to? Y/N describe:
Is there a particular place that your dog displays aggression? Y/N describe
Does your dog display aggression to other animals? Y/N describe (species, sex etc)
How do you handle the situation when your dog display’s aggression, in particular what you have done if the dog has bitten:
Has your dog ever bitten hard enough to cause injury? Y/N describe:
If your dog has bitten how did you handle the situation, and what was your dog’s reaction?
How would you describe your dog’s body language and action when he/she is aggressive?
How would you describe your dog’s attitude at the time of aggression?
What is your dog’s recovery time after an aggressive episode?
Section Fourteen: Miscellaneous InformationAnxiety’s and fears:
Does your dog ever cower or run away if people talk to loudly or act boisterously?
Is your dog comfortable in crowds? Y/N describe:Does your dog have noise sensitivity? Description:
Does your dog have any phobias, excessive fears or panic? Y/N describe:
Does your dog display timidity, shyness? Y/N describe:
Repetitive, compulsive, and unusual activities: HIGHLIGHT any that apply
Staring / Jumpy / Sucking / Tail chasing / Sucking / Light chasing / Fly chasing
If circled any of the above, describe:
Normal grooming? Y/N excessive licking Y/N Self-injurious Y/N
If yes to above, describe:
General: HIGHLIGHT any that apply
Jumps up owners
/ Jumps up at strangers / Mouth’sWon’t come when called
/ Pushy/demanding / Sometimes ignoresOn furniture where not allowed
/ In rooms where not allowedActivity: normal inactive restless highly active overactive
Sleep: normal increased less frequent restless sleep night waking
Exploratory: normal infrequent increased excessive
Bin raiding: food stealing Y/N Eats non food items (pica) Y/N Licks objects Y/N
Stool eating: Owns stools Y/N other dogs Y/N cats Y/N other Y/N
If yes to any of the above describe:
Destructive: chewing Y/N digging Y/N other: describe:
Chasing Y/N describe
Hunting / predatory Y/N describe
Vocalisation: barking Y/N Howling Y/N Whining Y/N describe
Sexual habits: mounting Y/N roaming/running away Y/N other – describe
Section Fifteen: Additional Information
Anything else you need to tell me? i.e do you suffer from any disabilities or difficulties which may need consideration?
PLEASE ENSURE YOU READ AND SIGN THE FOLLOWING
Terms & Information
Behaviour & Training Policy
This service is aimed at helping people to overcome behaviour problems they are experiencing, to train their dog or both.
Pooch Paws accepts no liability if any problems become worse or do not improve.
Pooch Paws can only guide and give advice; it is the owner's responsibility to enforce changes.
Sessions booked for a weekend are carried out at St.Olaves village hall. Cases of human aggression are to be assessed at the hall.
Location based sessions can be carried out at your home, on a walk, or another suitable location. Location sessions are during day time hours on a weekday. Please check the booking page.
Assessment and treatments plans will be based upon qualified knowledge, current scientific theory and experience. Suggestions for behaviour management will be provided during the assessment and a full written report will be sent by post, email, or in person within approximately 14 days. A copy of the report will be sent to the referring veterinary surgeon, with personal information considered private or sensitive, excluded.
Canine behaviour therapy can be integral to identifying causes of behaviour problems, to then develop a treatment plan to overcome these issues. In some cases, causes may not be identifiable and treatment plans may not be as effective as desired. Whilst this is unusual, those seeking behaviour therapies should be aware of this possibility. Implementing treatment plans may produce desired results quickly; however, time and commitment is required. This should always be considered as often a behaviour problem has spent a significant amount of time developing, therefore your perception of treatment needs to reflect how long the issues have been manifesting for. Implementation remains, at all times, the responsibility of the owner. The pet’s wellbeing, welfare, and actions are also the responsibility of the owner.
Behaviour reports and treatment plans are created according to the information provided by the owner, the information gleaned on assessment, and information provided by referring veterinary surgeons. In any case full co-operation from the owner, including full disclosure of any/all problems being experienced is needed. Withholding information can affect the plan, including withholding information regarding health matters. In any case advise to seek veterinary assistance may be given, which should be a priority for the owner.
PLEASE ENSURE YOU PROVIDE FULL DISCLOSURE IN ANY CASES REGARDING HUMAN AGGRESSION. IN THIS CASE SAFETY IS THE PRIORITY AND CAN NOT BE TAKEN LIGHTLY. FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN THE SERVICE BEING TERMINANTED, ESPECIALLY WITH LOW OWNER COMMUNICATION.