Behavior Intake Form Please complete and submit at least 48 hours prior to your consultation. If not received within the allotted time, your consultation will be cancelled or rescheduled. Thank you. Date -Month -DayYearDate Name First NameLast Name Address Street Address Street Address Line 2 CityState / Province Postal / Zip Code Email example@example.com Phone Number* Please enter a valid phone number. Household Members Please list all members who live in the household along with their age. Name Age Name Age Name Age Name Age Name Age Dog Information Dog's Name Age* Sex Male NeuteredMale UnalteredFemaie SpayedFemale Unaltered Veterinarian City/State Dog's Lifestyle What brand of food do you feed? How much do you feed your dog daily? What does your dog eat in a typical 24 hour period? Describe a typical 24 day for your dog. What is your dog's favorite thing to do? What is your dog's favorite treat? Who is your dog's best friend? (human or animal) List all animals residing in your home Provide the name, animal type/breed, and age who reside in the home with your dog. Name Type/Breed Age Name Type/Breed Age Name Type/Breed Age Name Type/Breed Age Medical Does or has your dog had any serious medical conditions? YesNo If yes, please list each and provide current status of condition. Does your dog take any medication? YesNo If yes, please list all medications including monthly flea/tick treatments. Behavior What is your primary behavior concern? Provide the approximate age you first noticed this behavior. Describe 2 - 3 incidents regarding this behavior. Stick to facts. Provide the date of the incident then describe what happened just before each incident, during the incident, and immediately after. What is your secondary behavior concern? Provide the approximate age you first noticed this behavior. Describe 2 - 3 incidents regarding this behavior. Stick to facts. Provide the date of the incident then describe what happened just before each incident, during the incident, and immediately after. What is your tertiary behavior concern? Provide the approximate age you first noticed this behavior. Describe 2 - 3 incidents regarding this behavior. Stick to facts. Provide the date of the incident then describe what happened just before each incident, during the incident, and immediately after. How does your dog behave around unfamiliar people? How does your dog behave around friends and family? Is there anything else you would like your consultant to know? How does your dog behave around unfamiliar dogs and/or cats? Had your dog ever bitten a human or animal? If yes, please complete the next question. If you answered yes, please provide details about any bite incidents. Please be honest. This information is confidential. Submit Should be Empty:
