Dog Behavior Questionnaire Please enable JavaScript in your browser to complete this form.About YouYour first name *Your last name *Email *Street address *City *State *ZIP code *Telephone number *About Your DogDog's name *What breed or breed mix is your dog?How many pounds does your dog weigh?What sex is your dog?MaleFemaleIs your dogs spayed or neutered?YesNoWhat is your dog’s current age?How old was your dog when you got him or her?Where did you get your dog?BreederShelterRescue GroupFoundPrivate AdoptionYour Dog's BehaviorBriefly describe your dog’s behavior problems. List them in order of concern for you.When did you first notice these behaviors? Has your dog growled at, barked at, or otherwise behaved menacingly towards a person?YesNoBehavior ScreeningPlease click all that apply for each question. Skip questions that do not apply to your dog.When being petted on the head of shoulder my dog hasGrowledBarkedAir snappedBittenWhen being hugged or kissed my dog hasGrowledBarkedAir snappedBittenWhen a human reached for my dog my dog hasGrowledBarkedAir snappedBittenWhen a human bent over my dog my dog hasGrowledBarkedAir snappedBittenWhen touching my dog’s feet my dog hasGrowledBarkedAir snappedBittenDuring grooming my dog has GrowledBarkedAir snappedBittenDuring a vet exam my dog hasGrowledBarkedAir snappedBittenWhen being restrained my dog hasGrowledBarkedAir snappedBittenWhen startled or awoken my dog hasGrowledBarkedAir snappedBittenWhen corrected or reprimanded my dog hasGrowledBarkedAir snappedBittenWhen leash corrected my dog hasGrowledBarkedAir snappedBittenWhen pulled or pushed off furniture my dog hasGrowledBarkedAir snappedBittenWhen I reached for the collar my dog hasGrowledBarkedAir snappedBittenWhen I pass the food bowl my dog hasGrowledBarkedAir snappedBittenWhen I pick up the food bowl my dog hasGrowledBarkedAir snappedBittenWhen my dog has a chew toy my dog hasGrowledBarkedAir snappedBittenWhen I try to take a toy my dog hasGrowledBarkedAir snappedBittenWhen I try to take a stolen item away my dogGrowledBarkedAir snappedBittenWhen a visitor comes in the front door my dog hasGrowledBarkedAir snappedBittenWhen a visitor looks at my dog my dog hasGrowledBarkedAir snappedBittenWhen a visitor talks to your dog my dog hasGrowledBarkedAir snappedBittenWhen approached by a toddler or infant my dog hasGrowledBarkedAir snappedBittenWhen approached by a child my dog hasGrowledBarkedAir snappedBittenWhen I show affection to my spouse my dog hasGrowledBarkedAir snappedBittenWhen someone approaches my car my dog hasGrowledBarkedAir snappedBittenHas your dog ever bitten a person?YesNoDescribe the last three bite incidents as you remember them:Bite oneDate and time of biteWhere was your dog when this happened?Who did your dog bite?What part of the person’s body was bitten?In your own words, briefly describe what was happening right before the bite occurredWhich of these best describes the bite (select one)Level One: Menacing behavior or air snap but no skin-contact by teeth.Level Two: Skin-contact by teeth but no skin-puncture. However, may be skin nicks (less than one tenth of an inch deep) and slight bleeding caused by forward or lateral movement of teeth against skin, but no vertical punctures.Level Three: One to four punctures from a single bite with no puncture deeper than half the length of the dog’s canine teeth. Maybe lacerations in a single direction, caused by victim pulling hand away, owner pulling dog away, or gravity (little dog jumps, bites and drops to floor)Level Four: One to four punctures from a single bite with at least one puncture deeper than half the length of the dog’s canine teeth. May also have deep bruising around the wound (dog held on for N seconds and bore down) or lacerations in both directions (dog held on and shook its head from side to side).Level Five: Multiple-bite incident with at least two Level 4 bites or multiple-attack incident with at least one Level 4 bite in each.In your own words, describe how the dog behaved after the biteHow was the person bitten cared for? Click all that apply.No specific care givenWound was cleaned at home.Person was taken to an emergency medical facility for cleaning and bandaging.Person was taken to an emergency medical facility for stitches.Person received prescription antibiotics.Surgery was required.Physical therapy was required.Bite twoDate and time of biteWhere was your dog when this happened?Who did your dog bite?What part of the person’s body was bitten?In your own words, briefly describe what was happening right before the bite occurred (copy)Which of these best describes the bite (select one)Level One: Menacing behavior or air snap but no skin-contact by teeth.Level Two: Skin-contact by teeth but no skin-puncture. However, may be skin nicks (less than one tenth of an inch deep) and slight bleeding caused by forward or lateral movement of teeth against skin, but no vertical punctures.Level Three: One to four punctures from a single bite with no puncture deeper than half the length of the dog’s canine teeth. Maybe lacerations in a single direction, caused by victim pulling hand away, owner pulling dog away, or gravity (little dog jumps, bites and drops to floor)Level Four: One to four punctures from a single bite with at least one puncture deeper than half the length of the dog’s canine teeth. May also have deep bruising around the wound (dog held on for N seconds and bore down) or lacerations in both directions (dog held on and shook its head from side to side).Level Five: Multiple-bite incident with at least two Level 4 bites or multiple-attack incident with at least one Level 4 bite in each.In your own words, describe how the dog behaved after the biteHow was the person bitten cared for? Click all that apply.No specific care givenWound was cleaned at home.Person was taken to an emergency medical facility for cleaning and bandaging.Person was taken to an emergency medical facility for stitches.Person received prescription antibiotics.Surgery was required.Physical therapy was required.Bite threeDate and time of biteWhere was your dog when this happened?Who did your dog bite?In your own words, briefly describe what was happening right before the bite occurredWhich of these best describes the bite (select one)Level One: Menacing behavior or air snap but no skin-contact by teeth.Level Two: Skin-contact by teeth but no skin-puncture. However, may be skin nicks (less than one tenth of an inch deep) and slight bleeding caused by forward or lateral movement of teeth against skin, but no vertical punctures.Level Three: One to four punctures from a single bite with no puncture deeper than half the length of the dog’s canine teeth. Maybe lacerations in a single direction, caused by victim pulling hand away, owner pulling dog away, or gravity (little dog jumps, bites and drops to floor)Level Four: One to four punctures from a single bite with at least one puncture deeper than half the length of the dog’s canine teeth. May also have deep bruising around the wound (dog held on for N seconds and bore down) or lacerations in both directions (dog held on and shook its head from side to side).Level Five: Multiple-bite incident with at least two Level 4 bites or multiple-attack incident with at least one Level 4 bite in each.In your own words, describe how the dog behaved after the biteHow was the person bitten cared for? Click all that apply.No specific care givenWound was cleaned at home.Person was taken to an emergency medical facility for cleaning and bandaging.Person was taken to an emergency medical facility for stitches.Person received prescription antibiotics.Surgery was required.Physical therapy was required.Has your dog ever bitten another dog?YesNoBriefly describe the most three most recent incidents in which your dog bit another dog.Describe any other behavior that you'd like to help your dog change.Your Dog's Everyday LifeHow many people live with your dog?Ages of children who live with your dogDo children under the age of 16 ever visit your home?YesNoList other animals who live in your home (Type, age, name)Does your dog regularly and successfully play with other dogs?YesNoHow much time does your dog spend alone (without human beings) per day?with people all dayalone 1-3 hoursalone 3-6 hoursalone 6+ hours per dayWhere Are They Kept When Alone?in fenced yardin yard with invisible / electric fencein crate indoorsin crate outdoorsin garagein certain parts of the househas free run of the houseDoes your dog use a doggie door for free access outside?YesNoWhat do you feed your dog?How do you feed?food is always available in a bowlbowl-fed at set feeding timesWhat are your dog's favorite toys?Briefly describe a typical day in your dog's life. Include routines and daily exercise if any.Which veterinary clinic / hospital do you use? *Health InformationWhich veterinarian do you usually see? List any medical conditions for which your dog is currently being treated.Do the medical conditions above (if any) cause frequent or chronic pain?YesNoList any medications your dog is currently taking other than heart worm or flea prevention. Are any of the above medications specifically prescribed for behavior issues?YesNoHave you taken a group class with your dog?YesNoTraining HistoryIf Yes, where? Have you and your dog had private behavior coaching?YesNoIf Yes, with whom?Has your dog been trained at a board-and-train facility?YesNoIf Yes, where? How do you respond when your dog does something right? How do you respond when your dog does something wrong?Which training tools do you use, if any?FoodClickerProng CollarChoke CollarShock CollarHead HalterWhich of the following cues will your dog respond to if there are NO distractions and if you DO NOT have food in your hand (click all that apply)SitLie DownHand TargetingCome When CalledResponds to NameKennel or CratePolite Leash WalkingList any other tricks or behaviors on cue:Final QuestionHow did you hear about Michael’s Dogs Behavior Group? (list all that apply)Google SearchReferred by my VetNextdoor AppFacebookInstagramRedditIf referred by Friend or Family please list their name Submit
