No Dog Too Small

Behavioral Questionnaire

Please review this entire questionnaire first, then go back and answer the questions as thoroughly as possible. If there was an incident (such as a bite), please ask those who were present for input as well.

Date

First name

Last name

What is the main issue you are concerned about? (Check all that apply.)

Aggression toward unfamiliar dogs

Aggression toward family member(s)

Aggression toward visitors

Aggression when handled/picked up

Aggression toward another dog or pet in the home

Guarding food / toys / possessions / other

Aggression toward unfamiliar people in public

Aggression toward vet / groomer / petsitter / dog walker

Other

When did this behavior start? (approximate date or how long ago)

Please check off any of the following that coincide with the change in your dog's behavior:

Please provide a general description of the issue, including as much specific information as possible:

What, if anything, has been done to address the issue so far?

If steps have been taken to address the issue, did your dog's behavior improve, worsen, or stay the same?

If your dog has threatened or bitten another dog, please check all that apply.

If your dog has threatened or bitten a person, please check all that apply.

For each specific incident, please provide the following information. (Copy this section on to another page if you need to provide information about more than one incident.)

Date of incident:

Location of incident:

Who was present?

What other dogs/animals were present?

Was your dog on leash?

YES

NO

If so, who was holding the leash?

What preceded the incident?

Had your dog been feeling well prior to the incident?

Did your dog give any warning signals? If so, what were they?

If there was a bite:

What was the location on the body?

Did it cause bruising?

YES

NO

Was there bleeding (torn skin)?

YES

NO

Was there a puncture wound?

YES

NO

Were there multiple puncture wounds?

YES

NO

Did the dog bite, latch on and shake his head from side to side, not letting go?

YES

NO

How did the incident end (for example, pulled dogs apart, one dog walked away, person ran away)?

What happened right after the incident (for example, put dog in yard, hit dog, dog laid down, dog looked “guilty”)?

If there was a bite, was medical help sought?

YES

NO

If there was a bite, was it reported?

YES

NO

If there was a bite, was legal action taken?

YES

NO

Which of the following best 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 if it remains unchanged we will live with it.

The problem is very serious. I would like to change it, but if it remains unchanged I will keep my dog.

The problem is extremely serious. I would like to change it; if it remains unchanged I will give my dog up or have him/her euthanized.

Other

Is there anything else you feel we should know?

Thank you for taking the time to complete this questionnaire.

Please return it with the Client Information Form.

No Dog Too Small

Deborah Maida, Owner

(781) 218-9217

info@nodogtoosmall.com