BEHAVIOR MODIFICATION CONSULTATION QUESTIONNAIRE

  • Date Format: MM slash DD slash YYYY
  • Dog's Information

  • Date Format: MM slash DD slash YYYY
  • The Home Environment

  • DAILY ACTIVITIES AND ROUTINE

  • TRAINING

  • PUNISHMENT

  • HANDLING

  • HOUSETRAINING

    (please complete this section if you require assistance with housetraining your dog)
    If No, please continue to answer the following questions
    If No, please continue to answer the following questions
    (choose all that apply)
  • MEDICAL

    (Choose one)
  • HOME ALONE BEHAVIOUR

    (If No, please skip ahead to next section) If Yes, please continue to answer the following questions
  • (list problems and how long after departure they occur):
  • REACTIVITY

    indicate how your dog reacts to each of the following (check all that apply)
  • AGGRESSION SCREEN

    (Please complete this section if there have been signs of aggression (growling, bite attempts, biting)
    Situations causing aggression (check all that apply)
    Situations causing aggression (check all that apply)
    Situations causing aggression (check all that apply)
    Situations causing aggression (check all that apply)
  • PRIMARY COMPLAINT

    (choose one)
  • MISCELLANEOUS

    (non-aggressive), e.g., ears back, cowering, tail tucked, shaking, retreating, hiding, etc.