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Medical Conditions: Please list

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GENERAL INFORMATION

GENERAL INFORMATION

Where did you acquire your dog?

How old was your dog when you acquired it?

Do you have any information about the previous owners?

Explain what you know about them in relation to your dog.

How does your dog spend the majority of its day?

Dog's environment (i.e. apartment, fenced yard, city life, rural)

How often is your dog exercised daily?

Daily exercise routine? (i.e. 3 thirty-minute walks, fetch in yard)

What are some of your dogs favorite toys?

Exercise restrictions

How long in crate daily?

How is your dog when home alone?

List each family member, Gender/Age

Household change (i.e. moved, new humans, new pets). Explain

Behavior with children?

Interaction with other animals

Reaction to strangers?

Behavior around other dogs?

TRAINING

TRAINING

What basic skills does your dog know?

Have you acquired any training for your dog?

What type of training/class?

How much time of training?

Training methods used?

Impressions of training

Most undesirable behavior

When was problem noticed?

How often is behavior practiced?

What have you done so far?

What do you think is the cause?

Which best describes your situation? (can select more than one)

I'm curious, the problem is not that serious

I would like to change the problem, but it's not that serious

The problem is serious, but if it remains unchanged that's OK

The problem is very serious, but if it remains unchanged, I will keep my dog

The problem is very serious. If it remains unchanged, I will consider rehoming or euthanasia.

BEHAVIORS

BEHAVIORS

Overly Submissive/Appeasement Behaviors

Excessive Excitability (unable to settle)

INCIDENTS

INCIDENTS

Aggressive towards family members? (list who)

Episodes of aggression? (describe all episodes of aggression including threats)

People Dog is not aggressive towards

Bitten a person - describe incident with as many details as possible

BITE LEVEL CHART

BITE LEVEL CHART (Based on Dr. Ian Dunbar's bite level scale)

Level 1: Dog growls, lunges, snarls-no teeth touch skin. Mostly intimidation behavior.

Level 2: Teeth touch skin but no puncture. May have red mark/minor bruise from dog’s head or snout, may have minor scratches from paws/nails. Minor surface abrasions acceptable.

Level 3a: Punctures ½ the length of a canine tooth, one to four holes, single bite below Level 4. May be lacerations in a single direction, caused by victim pulling away, owner pulling dog away, or gravity (little dog jumps, bites and drops to floor).

Level 3b: the dog bites multiple times leaving skin punctures shallower than half of the canine. Multiple bites generally mean the dog is in a higher arousal state.

Level 4: One to four holes from a single bite, one hole deeper than ½ the length of a canine tooth, typically contact/punctures from more than canines only. Black bruising, tears and/or slashing wounds. Dog clamped down and shook or slashed victim.

Level 5: Multiple bites at Level 4 or above. A concerted, repeated attack.

Level 6: Any bite resulting in death of a human.

Bitten an Animal (Wild/Domestic) - describe incident with as many details as possible

List Bite Level – see BITE LEVEL CHART

Killed Any Animals - Explain

Most Recent Bite Incident Was on What Date

EPISODES OF AGGRESSION TOWARDS PEOPLE

EPISODES OF AGGRESSION TOWARDS PEOPLE

Attacks are sudden & surprising

Yes

Episodes appear unprovoked

Yes

Dog appears docile after an episode

Yes

Dog appears “sorry” after episode

Yes

Dog appears disoriented after episode

Yes

Dog appears “glazed over” or “absent” during/after episode

Yes

I can tell what will set my dog off

Yes

The behavior is new

Yes

DOG'S REACTION

DOG'S REACTION

Approached While Eating Dog Food (can select more than one)

Engaging in Play (i.e. fetch, tug, puzzles) (can select more than one)

Gets Highly Aroused – becomes mouthy and jumpy, unable to settle

Fearful Backs Away – movements scare dog and has no interest

Plays Nicely – not mouthy and follows cues, enjoys activity

Approached While Chewing on Toy (can select more than one)

Approached While Sleeping (can select more than one)

Vehicle Manners (can select more than one)

Pants/Paces

Head out the window

Resting in back/rear of vehicle

Trembles/drools

Reactive to people/dogs

Vomits/Urinates/Defecates

Sits on lap/front seats

Secured in back/rear of vehicle

Window/Door Triggers (can select more than one)

Loves to quietly watch all that is going on

May bark once or twice at passers by – dogs, people

Incessant barking until no longer visible

Snarling, growling, barking

Lunging, charging, barking, snarling, slams into window/door

Unable to settle long after the visual trigger

People Visit in the Home (can select more than one)

Settles after they come it and sit

Fearful, runs away, cowers, hides

Fear aggression, barks, snaps, lunges, bites

Controllably Excited

Over Aroused, Rude, Jumps

Visitors Enter Yard (can select more than one)

Fearful, runs away, cowers, hides

Fear aggression, barks, snaps, lunges, bites

Controllably Excited

Over Aroused, Rude, Jumps

When Reached for or Touched (can select more than one)

Petted or Hugged (can select more than one)

Lifted (can select more than one)

Moved from Furniture (can select more than one)

Trimming Nails (can select more than one)

Grooming/Brushing/Bathing (can select more than one)

Cleaning Ears (can select more than one)

Rubbing Belly (can select more than one)

Grabbing Collar (can select more than one)

Being Put in Crate (can select more than one)

Additional Comments: Your goals, good things about your dog, etc. comment box

TERMS & CONDITIONS

Terms and Conditions

As a condition of service, I understand, certify and agree:

That my dog is current with all state-required vaccinations

I am aware of the risks of handling animals, such as personal injury or property damage to myself, my pet(s), or to members of my family

That I assume full responsibility for any actions of my dog(s) and agree to hold harmless and indemnify person(s) associated with Mutt Palace Canine Services

Cancelation Policy:

Our policy requires a minimum of a call/text/email 48 hours before the private session is scheduled, otherwise, the private session will not be refunded.

Refund Policy:

Should the client opt to terminate services, they are eligible 75% of paid sessions not used.

Acceptable forms of payment:

Cash

Check - Payable to Mutt Palace

PayPal - michelle@muttpalace.com

Venmo: 717-278-0370

I accept the above Terms and Conditions

I accept the above terms and conditions