CEDARBURG PET CARE LLC
SHY DOG QUESTIONNAIRE
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Email *
Today's Date *
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Owner's Name(s): *
Owner's Phone # *
Owner's Street Address: *
Dog's Name: *
Breed: If a mix, list two predominant breeds in behavior: *
Dog's Sex: *
Is your dog spayed or neutered? *
Dogs Birthdate/Age: *
How Long have you owned your dog?: *
How old was your dog when acquired?: *
Has your dog had previous owners? If so, how many: *
If prior owners-Why was he/she given up:
Where did you get your dog? *
Did you meet your dog's biological parents or know anything about his/her littermates? *
Was temperament testing performed? *
Has  your dog attended any training classes? *
Has a dog trainer come to your home? *
Have you ever consulted with a behavior specialist? *
Which of the following best describes your dog's level of socialization with other dogs: *
What concerns do you have with your pet's behavior?  At what age did the problem begin?
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Who (people) lives in the same home as your pet?  (Name, age, sex, relationship to you, average # of hours away from home per day, quality of relationship with your dog)
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List ALL other pets that live in the same home as your pet.  (Names, species, breed, sex, spay/neutered?, age obtained, age now, was pet acquired before or after your dog?, quality of relationship with your dog)
What type of home do you live in?
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Do you have a yard?  If so, what type of fence do you have?
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Have there been changes in your household since acquiring your dog?  If so, how?
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How many times is your dog walked on leash per day?
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What is the average length of  walks?
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How many times is your dog let out in the yard each day?
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How long is your dog out for?
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Does anyone go in the yard with him/her?
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How many hours per day is your dog unsupervised outside?
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Is there a dog door to go outside?
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Where is your dog when home alone? (room, crate, loose, outside?)
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Does your dog have access to the entire house at all times?
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Where does your dog go when you have guests?
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How do you play with your dog?
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Does your dog ever urinate in the house?
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Does your dog ever defecate in the house?
How does your dog behave when you prepare to leave the house?
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How does your dog behave when you return home?
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What does your dog eat?
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How many meals is your dog offered per day?  Do they finish each meal?  Does someone have to be present for your dog to eat?
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Where is the dog's food bowl?
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If other animals eat at the same time, is it in the same room?
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Does your dog have any food allergies or diet restrictions?
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Is water available 24/7?
At what age was your dog neutered/spayed?
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Has your dog ever been bred?
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Are you planning to breed your dog?
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Is your dog on heart worm and flea prevention?
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Please list any other medications your dog takes.
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Does your dog have any medical problems?
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What is your dog's relationship with other animals in your household?
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What is your dog's response to new dogs?
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Does your dog interact with other dogs outside the house on a regular basis?  When and where?
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What does your dog think about cats or other small animals outside of your home?
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Have there been any aggression (growling, showing teeth,  lunging, nipping, snapping, or biting) with any FAMILY MEMBER (who?) in the following situations:
-Petting or reaching for dog?
-Hugging or kissing dog?
-Bending over dog?
-Making eye contact with dog?
-Bathing, grooming, drying dog?
-Trimming nails?
-Disturbing dog when resting?
-Removing from furniture?
-Giving verbal or physical corrections?
-Approaching when dog has bone, treat, or chew toy?
-Putting on leash or collar?
-Grabbing collar?
-Lifting dog?
-Any other instance?
Has there been any aggression with NON-HOUSEHOLD members in the following situations?
-Petting or reaching for dog?
-Bending over dog?
-Making eye contact with dog?
-Entering your house or yard?
-Enter/exit any room in your home?
-Passing when dog is on leashed walk?
-Passing when dog is in car?
-Interacting with dog on leash?
-Putting on leash or collar?
-Grabbing collar?
-Runners/joggers/bikers?
-Any other instance?
Has your dog ever bitten a person?  How many times? Did any bites break the skin?
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Does your dog act fearful in the following situations?  If so, how? (dilated pupils, trembles, cowers, tucks tail, hides, escapes, destructive, vocalizes, drool, defecate, urinate):
-Normal day at home with family member
-Dog is home alone
-Dog is home alone with another pet
-Dog and family members are home, but separated (ie different room, crate)
-Dog is home alone in crate
-Dog is at veterinary office
-Dog is at groomer
-Fireworks
-Thunderstorms
-Loud noises
-Flashes of light
Are there any other fearful stimuli? (ie men, umbrellas, vacuum)
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How did you housetrain your dog?
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Has your dog ever been crated?  Do you continue to use it?
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What commands can your dog reliably perform?
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Does your dog ever lick people, himself, or objects excessively?
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Does your dog mount people, dogs, or objects?
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If your dog sensitive to have certain body parts handled (ie ears or feet)?
Have you tried any of the following behavioral corrections, and how did your dog respond?
-Stare down
-Grab by jowls/scruff +/- shake
-Shake or throw a can
-Force down by leash
-Time out (where, when, how long?)
-Metal choke or pronged collar
-Water pistol/spray
-Halti collar or Gentle Leader
-Easy Walker Harness
-Bark or remote activated shock collar
-Invisible/electric fence
-Citronella spray collar
-Forced exposure to fearful stimuli
-Knee dog in check for jumping
-Hit or kick dog
-Growl at dog
-Lift dog by leash or collar
-Rub dog's nose/face into urine, feces, or area of destruction
-Tether to wall or floor with short lead
-Tether/tie out in yard
-Yell "no"
-"Alpha roll" (hold on back)
-"Dominance down" (hold on side, legs extended, head flat)
-Crate
-Command to sit or lie down for extended period
-Agility or other sport activity
-Use of food or puzzle toys
-Praise for good behavior
-Food rewards for good behavior
-Kennel outdoors
-Muzzle
-Command dog to "look" or "watch me"
-Increase play/exercise
-Clicker training
-Feed meals by hand
-Remove food bowl while eating
-Phermones (DAP, Comfort Zone)
-Anything else?
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