Client History Form | Cognitive Dogs

Contact Information

Name*

First Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone*

Mobile Phone*

Occupation

How did you hear about us?*

Dog Information

Dog's Name*

Breed*

Gender*

Age*

Weight*

Where did you get your dog?*

Age Obtained*

Veterinarian Information

Do you currently have a preferred veterinarian?*

Is your dog currently on any medication(s)?*

Equipment

Equipment currently used:*

Please select all that apply.

Training History

What is your level of experience?*

Have you done any previous training with this dog?*

Is your dog house trained (aka potty trained)?*

Is your dog crate trained?*

Daily Routine

What is your dog's main meal source?*

Kibble
Wet (canned) food
Frozen/Fresh Raw
Freeze dried Raw
Cooked

What brand of food do you feed your dog?

How many meals per day?*

What kinds of treats do you use?

Does your dog have any food allergies or diet restrictions?*

Where is your dog when you are NOT home"?*

How many hours per day is your dog left alone?*

Where does your dog sleep at night?*

What type(s) of physical activity does your dog receive and how often?*

Social Interactions

Please list all members of the household, including any children.*

**Please include ages of any children.

Please list any other pets in the home (species, breed, age, gender).*

**PLEASE NOTE: If we will be providing behavior consultation and training services for more than one dog, you will need to complete a separate Client History Form FOR EACH DOG.**

Is your dog friendly towards other people?*

Is your dog friendly toward other dogs?*

Do you currently take your dog to any off-leash dog parks/beaches?*

Do you currently take your dog to doggy daycare?*

Do you currently use a dog walker?*

Behavior Information

Please describe behavior concerns in order of severity and/or priority.*

Are you having problems with any of the following?*

Please select all that apply.

Has your dog ever bitten another dog?*

Please list each incident, approximate date(s), and severity of bite.*

Has your dog ever bitten a person?*

Please list each incident, approximate date(s), and severity of bite.*

Have any of these bites been reported to Animal Control?*

Have you ever considered relinquishing or rehoming your dog?*

Have you ever considered euthanizing your dog due to his/her behavior?*

Is there anything else we should know about your dog?*

Training Goals

What are your training goals?*

Email

This field is for validation purposes and should be left unchanged.

CLIENT
HISTORY

About My Dog

Contact Information

Dog Information

Veterinarian Information

Equipment

Training History

Daily Routine

Social Interactions

Behavior Information

Training Goals

CLIENTHISTORY

About My Dog

Contact Information

Dog Information

Veterinarian Information

Equipment

Training History

Daily Routine

Social Interactions

Behavior Information

Training Goals

CLIENT
HISTORY