Thank you in advance for completing this detailed questionnaire!
This information will help me to understand your dog’s situation, behavior and training issues so we can get started training right away for companion or service work!

General Information
Today’s Date:
Your Name:
Address:
Home Phone:
Cell Phone:
How were you referred to K9-Behavior Company?
If you already have a dog you would like to train for service work please provide the following:
Pet’s Name:  
Pet’s Breed:  
Pet’s Sex: Male or Female  
Pet’s Birth Date or Age:  
Pet’s Vet Clinic:  
How much does your dog weigh approximately?  
Is your dog over or under weight?  
Is your dog spayed or neutered?       		If so, at what age?

What prompted you to decide to get training or behavior modification assistance now?  Is there some specific incident that caused you to seek assistance?  

Briefly describe your dog’s personality (quiet, confident, excitable, unruly, timid, fearful, aggressive, busy, etc)  

How old was your dog when you got it?  

From whom/where did you get the dog?  

Do you have any specific information about previous owner history or behavior problems?  

What motivated you to get a dog and this particular breed?  

Please describe any current medical problems your dog may have and if your dog is on any medication?  

Date of last rabies vaccination?             Date of last DHLPP vaccination?  

Do you have any special health or living circumstances that must be considered in keeping your dog?  
(Eg. allergies, asthma, neighbors sensitive to noise or dog activity, mobility limitations, etc) 

Service Task Topics

Please list the specific tasks you would like your service or companion dog to perform to assist with your disability.

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4.

Will you need your service dog to accompany you to public places? If so, please list the types of places:

School			Y or N
Work			Y or N
Grocery Shopping	Y or N
Other Shopping	Y or N
Airplane or other public transportation, bus, train etc.	Y or N
Other? Please describe . . . 

Are you or is the person that the service dog will work for able to perform some of the basic care needs for the dog?

Feeding		Y or N
Grooming		Y or N
Walking		Y or N
Playing games		Y or N
May the dog sleep in the same room with the handler?	Y or N

Other Dog Training / Behavior Concerns

If your dog has specific behaviors that concern you or needs basic training in addition to service task training, please list the training issues needing to be addressed.

Examples:  
Fido is afraid when people come to the front door – he needs help with confidence
Fido barks at other dogs and people when out on a walk if they get within 10 feet of us. 
Fido does not come when called.
Fido jumps on people he likes.
Fido pulls on the leash. 

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2.

3.

4.

5.

6.

In addition to regular play & exercise, how much time are you able or willing to spend training your dog?

	More than below
	3 - 10-minute sessions per day
	3 - 10-minute sessions per day
	1 - 10-minute session per day
	3 - 10-minute sessions per week
	1 - 10-minute session per week
	Less than above

Feeding

What kind/brand of food do you feed your dog?

How many times per day do you feed?

Do you leave the food bowl down for the dog most of the day?

Does your dog have any food allergies or special diet considerations? Please specify.

What are your dog’s eating habits? (voracious, picky, eats when s/he wants)

If you leave food for your dog, will s/he eat while you are gone?

If your dog is over or under weight what are you doing to change that?

Has your dog ever lunged, growled, or snapped at anyone around his/her food bowl?

Home Environment
Where does the dog sleep at night?

Where is the dog during the day when you are home?

Where is the dog when you are not home?

How many hours per day does the dog spend home alone?

Does your dog do unwanted behaviors (eg. chewing, digging, barking, or escaping) or cause damage to things or him/herself when you are gone?

Do you give treats to your dog? What type, how often and under what circumstances?

Does your dog take food or treats from your hand gently?  How about from other family members or strangers? 

Can you easily take things (food, toys, chew bones) away from your dog without him/her trying to keep the item, growling, running or snapping at you?

Do you have/use a crate for your dog? For what purposes & does the dog like the crate?

Activities with Dog

List the dog’s daily play and or exercise and how many minutes per day does s/he do each?

Dog’s Favorite game:

Dog’s favorite toy:

What are your dog’s top 5 favorite things to have or do in priority order? (eg, treats, specific toys, specific games like tug or fetch, activities like swimming, chasing squirrels or the dog park, etc.)

1
2
3
4
5

Does your dog know any tricks? Which ones?

What types of collars do you use? Note all that apply.

Flat buckle collar
Choke chain
Martingale (limited slip flat)
Pinch or Prong Collar
Leather flat
Gentle Leader
Halti
Regular Harness
Anti-pulling Harness
Invisible Fence Collar
Bark Collar
Shock Collar
Other Collar – please describe.

 Family Members

Please list family member names (ages if children), and how they get along with the dog:
Examples:
Sally	10 yrs old	Sally & dog play together all the time
Trina	3 yrs old	Trina is afraid of the dog because it bit her when she took dog’s bone
Howard – dad		Dog loves Howard – they play tug games every day

List other family pets, species, sex, acquired before or after the dog, and how they get along:

Examples:
Bird	male		had before	bird is caged & they don’t interact
Cat	female		had before	cat avoids dog; dog chases cat every time, cat runs never caught yet

Has the dog ever growled at or snapped at a family member? What were the circumstances?

Handling

How does your dog react to the following types of handling?  
1 = hates    2 = tolerates    3 = indifferent   4 = likes    5 = loves

Trimming Nails			
Brushing Teeth			
Bathing			
Grabbing Collar			
Examining feet, belly, tail, & ears	
Vet examination			
Being lifted				
Putting on collars & leashes		
Getting into the car			
Being asked to get off the bed/sofa	

Socialization

Did your dog attend a “puppy socialization” class at about 8-16 weeks of age?

How many NEW PEOPLE does your dog meet each week (i.e. people your dog does not know)? _______

How does your dog react to the following types of people? 
0 = is aggressive      1 = is shy or does not like  	2 = is indifferent	3 = is happy/loves 

Unfamiliar People
People in Uniforms
Men
Children
Teenagers
Women
Other Unfamiliar Dogs
Other Familiar Dogs

How many times has your dog bitten a person; family member or other non-family member?
What were the circumstances each time it happened?

What was the severity of each of the bites?
	Did not break skin – left spit only
Did not break skin – but bruised
Broke/Scratched skin
One-hole puncture or tear
2-4 hole puncture
More extensive damage to skin

Has your dog been in fights with other dogs? 	How many?
Out of those fights, how many times did either of the dogs have to go to the vet for treatment?

Do you take your dog to any off-leash dog parks on a regular basis?  How frequently?  How does it go there?

Training History

Did you attend obedience or other classes or training with your dog? 
What type & how many sessions?
Did they use food treats in class?		Did they use collar corrections in class?

Which cues does your dog know? 
3 = really well      2 = most of the time      1 = only sometimes      0 = doesn’t know

Sit		
Down		
Stay		
Come		
Walk on a Loose Leash	
Fetch		
Drop it		
Leave it	

How do your reward your dog when s/he does what you ask?

Which of the following methods, if any, have you used to correct your dog’s behavior?
Put a * by the ones that work best.
Put an X by the ones that don’t work well.
Put a W by any that make the behavior worse.
Leave blank if you have not used the method.

Swatting or Hitting
Pushing Away
Confinement
Verbal Reprimands
Shaker Cans
Alpha Roll-over
Choke Chain Corrections
Holding Nose Firmly & Saying No
Kneeing in the Chest
Turning Away
Squeezing Paws
Water Sprayer
Time-outs
“Actively” Ignoring
Give dog something else to do
Shock Collar Correction
Other – please describe

Have you ever used a ‘clicker’ to help train your dog?   Are you interested in learning how to use one?

Other Potential Issues

Below is a list of potential problem behaviors.  Please note any which you may also have questions or concerns about.

Digging	
Chewing	
Barking	
Howling		
Whining
House soiling/marking – urine	
House soiling – feces	
Urinating when excited or frightened	
Stool Eating	
Chasing	
Hunting or Predatory Behavior	
Jumping up on family or guests	
Jumping onto furniture where not allowed	
Stealing food off counters	
Raiding garbage	
Escaping from yard	
Running away		
Not coming when called	
Self-chewing	
Mounting children or others	
Shy of People		
Shy of Things		
Shy of Noises	
Biting		
Aggression	
Bad when Home Alone	
Phobias	
Begs at Dinner Table	
Pulls on Leash		
Other?????		

Thank you again for completing this questionnaire!
Please return to Deborah Walker by email at
K9BTraining@gmail.com or mail to:

Deborah Walker
K9-Behavior Company
PO Box 656
Wilbur, Oregon  97494