Canine Assessment Form

First & last name(required)

Email(required)

Phone number(required)

Address(required)

Dogs name(required)

Age(required)

Breed(required)

Sex(required)

Male Female Neutered male Spayed female

When and at what age did you acquire your dog?(required)

Where did you get your dog?(required)

What other pets live with your dog?(required)

What other humans live with your dog?(required)

Current veterinarian(required)

Last veterinary exam(required)

Do you consent that I contact your veterinarian for medical records?(required)

Yes No

Medical concerns(required)

Current medications & supplements(required)

Food sensitivities(required)

How is your dog at the veterinary hospital?(required)

Does your dog need assistance with husbandry behaviours?(required)

Nail trimming Ear cleaning Body handling and restraint Brushing teeth Blood collection Medication administration Veterinary exam None at this time

Other

Does your dog need help with good manners?(required)

Polite greetings Loose leash walking Sit/down/stay Recall Drop it/leave it/bring it Place/settle Crate training None at this time

Other

Has your dog done previous training?(required)

Puppy classes Obedience training Private instructor I trained my pet at home No previous training

If yes to the question above, what methods were used?

Positive reinforcement Balanced Dominance Punishment (physical, scare tactics, verbal reprimands etc.)

Behavioural concerns(required)

What do you feel is the function of the behaviour(s) mentioned above?(required)

What have you tried so far?(required)

Did it make the behaviour better or worse?(required)

Has your dog ever shown aggressive behaviour? If yes describe the events.(required)

How long is your dog home alone for?(required)

Does your dog exhibit any behaviour problems when you leave him/her alone?(required)

Does your dog show any signs of distress during loud events such as fireworks, thunderstorms, trucks, shouting?(required)