THE PEACEFUL POOCH ENROLLMENT FORM



A questionnaire to help me understand your dog’s behavior. Please be as specific as possible.

PLEASE NOTE: We have to say some legal stuff. Please bear with us. Completion of this form does not guarantee a spot in our program. We may have a waiting list, or we may believe it is best for you to be referred elsewhere. We reserve the right to refuse service.

WE DO NOT use the online booking app offered by Pocketsuite when you submit this form, so please do not download it for use with our services. We will book each session at the end of the previous session.
First name*
Last name*
Your Phone Number*
Email*
Additional Owner
Veterinarian Name
Veterinarian Number
Dog Name*
Dog Breed (if unknown please put "X")*
Dog Age (or best estimate)*
Dog Weight*
Dog Sex*
Male
Female
Dog is:*
Spayed/Neutered
Unaltered
Date of last vet visit (if known)
Any health issues?*
Yes
No
If yes, please explain
Dog Food Name *
Medications:
Please elaborate
What are the main issues you are concerned about?*
Aggression toward unfamiliar dogs
Aggression toward family member(s)
Aggression toward visiters
Aggression when handled or picked up
Aggression toward another dog or pet in the home
Guarding food, toys, or other possessions
Aggression toward unfamiliar people in public
Aggression toward veterinarian, groomer, dog walker, or pet sitter
When did this behavior start?*
Please check any that coincided with the start of the behavior :*
Dog has always been this way
Person moving out of home
New adult in home
New baby in home
New pet in home
Pet in home lost, died, or rehomed
Environmental change (for example, construction in the home)
Change in owner's work schedule
Change in amount of physical activity
Less time spent with dog
Moved
Change in diet
Recent vaccination
Recent veterinary visit
New medication
Medical treatment / surgery
Dog sent away for training
Other
Please elaborate if necessary
Please describe the issue with as much detail as possible :*
What, if anything, has been done to address the behavior?
If steps have been taken to address the problem, did your dog's behavior improve, get worse, or stay the same?
Improved somewhat
Improved greatly
Became somewhat worse
Became much worse
Stayed the same
Additional comments on results of previous actions:
If your dog has threatened or bitten another dog, please check all that apply
Growls, barks, and/or lunges at dogs on walks
Growls, barks, and/or lunges at another dog in the home
Has air snapped at another dog without contact
Play between dogs in the home escalates into fights
Bit another dog while your dog was off leash
Bit another dog while your dog was on leash
Bit another dog and drew blood
Bit another dog inflicted one puncture wound
Bit another dog and inflicted multiple puncture wounds
Tried to kill another dog (grab and shake)
If your dog has threatened or bit a person please select all that apply:
Threatened (growled, barked, air-snapped, lunged at) family member with no bite
Threatened a stranger in public with no bite
Threatened a visitor to the home with no bite
Bit a family member without breaking skin
Bit family member with scratch or tear
Bit family member with a single puncture wound
Bit family member, multiple puncture wounds
Bit stanger in public with no broken skin
Bit stranger in public with scratch or tear
Bit stranger in public with single puncture wound
Bit stranger in public with multiple puncture wounds
Bit visitor with no broken skin
Bit visitor with scratch or tear
Bit visitor with single puncture wound
Bit visitor with multiple puncture wounds
Bit veterinarian or staff
Bit groomer
Bit pet sitter/dog walker
Other (please elaborate below)
Bite to humans other or further description:
Which of the following describes your feelings about your dog's behavior issue?*
The problem is not serious, but I am curious about what you would suggest.
I would like to change the problem, but it is not that serious.
The problem is somewhat serious. I would like to change it, but we can live with it if we must.
The problem is serious, but I will keep my dog anyway.
The problem is very serious . If unchanged i will get rid of/euthanize my dog.
Other
If other, please elaborate:
Additional Notes