Behavior Intake Form

Jesse McClure, PhD CPDT-KA

Introduction

Please fill out the form below to request an appointment with Dr McClure for behavior services for your dog. Dr McClure can address a wide range of problem behaviors including anxiety and aggression. If, however, your primary goal is for basic training and your dog can safely interact with new people and dogs, please call Petropolis at 636-778-4989 to ask about training.

The information in this form will allow Dr McClure to come to your first session prepared to use the time most effectively. The form starts with general background and progresses to details about the concerns that brought you here today. Please take time to answer every question in as much detail as possible. If a question really does not apply, feel free to put “NA”, but do not leave any question blank.

Owner Information
Please list any previous dog's you've owned and when.
How did you hear about our behavior program?
Dog Information
When did this dog join your family?
How / why did you chose this dog?
Health Background
Have you discusssed the current issue with your vet? If so, what did they suggest?
Describe any health of physical issues your dog has.
Describe any prior illnesses and all surgeries with dates.
List all currently used medications.
List all previous medications and what they were for.
Nutrition
What brand(s) and flavors of food does your dog eat?
Describe this dog's feeding schedule (when, where, etc).
List any known food allergies or sensitivies.
What are your dog's favorite edible foods / treats?
Does your dog protect or guard food / treats from people or other dogs?
Home Environment
List the name, age, and gender of all people in the home.
List the name, age, and species/breed of all pets in the home.
How does your dog get along with each of their housemates
Where is your dog when you have guests over?
Do you have a securely fenced yard?
Do you use an electronic containment system (e.g., “Invisible Fence”)?
How do you exercise your dog?
What games do you play with your dog?
What are your dog's favorite toys or games?
Does your dog protect or guard toys from people or other dogs?
Training History
What level of / how much training has this dog had?
Who did the training?
What kinds of collars have you used with this dog?
What kinds of leashes have you used with this dog?
What other training equipment have you used?
What kinds of rewards do you use for this dog?
What kinds of punishments do you use for this dog?
List cues / commands that your dog responds to reliably (90% of the time).
List any tricks you've taught this dog to do.
Solo Time
How comfortable is your dog in their crate (“NA” if no crate is used)?
How much time each day (other than overnight) does your dog spend in a crate?
Where does your dog sleep at night?
Where is your dog when left alone?
What does your dog do as you are about to leave the home?
How does your dog act when you return home?
Describe any soiling or damage done by your dog when left alone.
Does your dog bark, whine, or vocalize excessively when alone?
Confidence / Anxiety
Describe your dog's energy or activity level.
Do you think this activity level is normal and appropriate for your dog?
Describe your dog's reaction to people coming to the door.
Describe your dog's reaction to strangers while on a walk.
Describe your dog's reaction to unfamiliar dogs while on a walk.
Describe your dog's reaction to thunderstorms or loud noises.
Does your dog startle to anything else (e.g., flashes of light, sudden movements, etc)?
Check each of the follow that you can readily do with this dog without a fuss:
Human-Directed Aggression
Which of the following best describes the worst bite to a human by this dog?

If you selected anything other than Level 0 above, please complete the following questions to describe in detail the worst human-directed bite by this dog:

How many times, excluding play, has there been tooth-to-skin contact from this dog?
Who received the worst bite from this dog?
Where was your dog?
Where was everyone else around your dog?
What was everyone doing just before the bite incident?
What did your dog do?
Describe your dog's body language (posture, ears, tail, face, hair, etc).
What was your reaction (or the reaction of the person responsible for the dog)?
What was the reaction of the victim / target?
Describe your dog's behavior immediately after the incident.
Did you attempt to punish or discipline your dog for this incident, and how?
Dog-Directed Aggression
Which of the following best describes the worst bite to another dog by this dog?

If you selected anything other than Level 0 above, please complete the following questions to describe in detail the worst dog-directed bite by this dog:

Where was your dog?
Who else (dogs and people) were around your dog?
What was everyone doing just before the bite incident?
What did your dog do?
Describe your dog's body language (posture, ears, tail, face, hair, etc).
What was your reaction (or the reaction of the person responsible for the dog)?
What was the reaction of the victim / target?
Describe your dog's behavior immediately after the incident.
Did you attempt to punish or discipline your dog for this incident, and how?
Primary Concerns
What is the primary behavior concern that led you to contact us?
How often does this problem behavior occur?
Describe in detail the most recent occurrence of this problem.
Describe in detail the most severe occurrence of this problem.
Describe in detail the first time you noticed this problem.
What have you tried so far to address the problem?
Are there other behavior concerns you are having?
Finishing Up
Are you willing to accept praise and critiques of your handling of your dog and cooperate with any recommendations made?
Are you willing to make changes to your dog's environment or routine, and accept suggestions regarding equipment changes, managing behaviour, veterinary check ups, etc?
Describe any concerns or hesitation you have to answering “yes” to the two previous questions:
List three things you love about your dog.

Please feel free to submit any of the following supplemental materials via email to jessem@petropolis.com:

Please double check all of your answers for clarity and completeness, then submit this form with the button below: