Client InformationFull Name Phone NumberEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country About my dogMy dog's name My dog's Breed My dog's Age Weight of dog 1. Do you crate your dog? Yes No For how many hours/day? 2. Do you have a fenced in space for your dog ? Yes No Physical fence or electronic fence system? 3. Where does your dog sleep at night? 4. If on a couch or bed, will your dog vacate the spot at your request? Yes No 5. Is your dog spayed/neutered? Yes No 6. Are your dog’s vaccinations up to date? Yes No 7. Are there other dogs in the home? Yes No If so, list: 8. Can your dog be safely left alone in your house? Yes No 9. Are there situations when your dog appears stressed? Yes No If so, list: 10. Have you taken your dog to any training classes? Yes No If so, describe type of class and with whom: 11. Does your dog easily comply with a request to give up anything in his/her possession? Yes No 12. Can your dog be petted, moved, or interrupted while eating? Yes No 13. Can all family members expect reasonable compliance to reasonable requests? Yes No 14. Is there a family member that your dog disregards or ignores? Yes No If so, who? 15. When guests arrive, is your dog out of control? Yes No What does your dog do? 16. When at the vet’s office will your dog allow itself to be restrained and/or examined without struggling, growling, or biting? Yes No 17. When you encounter other dogs, is your dog out of control? Yes No What does your dog do? 18. What are the situations that cause your dog to growl? What actions do you take? 19. Has your dog ever bitten a person? Yes No If yes, how many times: Describe each bite: Just cause a bruise? Break the skin? Stitches needed? Just cause a bruise? Break the skin? Stitches needed? 20. Has your dog been in a dogfight with another dog? Yes No If yes, how many times Check all that apply: Neither dog got hurt My dog had a few cuts My dog had at least one puncture wound The other dog had a few cuts The other dog had at least one puncture wound The other dog needed stitches 21. Are there situations in which you feel you have little or no control over your dog? Yes No If so, describe: 22. Has your dog ever been on a choke, pinch, or shock collar? Yes No If yes, how long? 23. Last visit with a vet? Name of veterinarian: 24. Any health problems? If so, describe: Any medications? If so, list: 25.What do you feed your dog? How much per day? 26. What are your goals for your dog? 27. Is there anything else you would like me to know about your dog? My dog has problems with: Men Men with (hats, beards, sunglasses, other: ) Women Kids (Ages: ) Mail or UPS Person Groups of people People walking People coming up from behind People running/jogging People on the other side of a fence or barrier Moving body parts (i.e. someone swinging their arms) Eye contact from strangers Being petted or touched Grooming (Define: ) My dog has problems with the following inanimate objects: Coats Hats Sunglasses Gloves Boots Umbrellas Stuffed animals Papers blowing in the wind Playground equipment Drainpipes Trucks Manhole covers Water (bath/lake/river/rain) Gravel Pots and pans dropping Loud music Shopping carts Thunder Other Other: My dog has problems with other dogs when they: Make direct eye contact Run Walk Play stand still approach the crate approach the car approach the yard approach the home Approaching head on Approaching fast Sniff my dog’s rear Are on leash Are off leash Puppies Male dogs (Intact or neutered) Female dogs (intact or spayed) Certain Breeds of dogs: Other Other:
