Owner Information

First Name *

Last Name *

Address *

City *

State *

Postal code *

Phone *

Email *

How Many Children Do You Have? *

Have You Ever Owned A Dog? *

How did you hear about K9Mania? *

Have you Ever Trained A Dog? *

Briefly State What You Hope To Accomplish In This Class: *

Dog Information

Dog's Name *

Dog's Breed *

Dog's Age *

How Old Was The Dog When You Aquired It? *

Gender *

Male

Female

How Long Have You Owned The Dog? *

Has Your Dog Been: *

Spayed

Neutered

None of the Above

Where Does Your Dog Sleep At Night? *

Is Your Dog House Trained? *

Behavior Problems Of Parents Or Littermates, if Known? *

Veterinary Information

Veterinarian *

Vet Clinic

Clinic Address *

Is Your Dog Current On All Vaccinations including Rabies? *

Yes

No

Vaccination Dates:

Rabies *

DHLP *

Please List All Medications Your Dog Is Currently Taking. Please Include Heartworm, Flea and Tick Medications, etc *

Please List Any Medical Problems Your Dog Has Had: *

Behavior Information

Describe Any Previous Obediance Training: *

Level Of Success? *

What Commands Currently Work Best? *

Which Member Of The Family Has The Best Control? *

Does Your Dog Know How To Walk On A Leash? *

Yes

No

How Does Your Dog Respond To The Following Tasks?

Trimming Nails? *

Giving Pills? *

Cleaning Ears? *

Grooming *

Bathing? *

Patting Head? *

Being Lifted? *

Rolling Over *

Tell Me About Any Correction Techniques You Have Used And Their Effect On Your Dog’s Behavior:

Time Out *

Leash Correction *

Verbal Scolding *

Noisemaker *

Water Spray *

Rollover *

Other Description. *

Describe Unwanted Behavior In Greater Detail: *

Describe How Your Dog Reacts To The Following Times When Left Alone:

During The Day: *

During The Evening: *

What Is Your Dog's Reaction To Your Departure? *

What Is Your Dog's Reaction To Your Homecoming? *

Do You Use A Crate? *

Yes

No

Does Your Dog Like The Crate? *

Yes

No

Does Your Dog Exhibit Any Of The Following Behaviors, and When Does It Occurs (With Men Or In The Car)

Cowering *

Ears Back *

Tail Tucked *

Retreating *

Hiding *

Excessive Salivating *

Pacing *

Please Give Additional Information Regarding Fear Or Anxiety In Your Dog: *

Describe Situations Where Your Dog Appears Fearful And/Or Aggressive: *

Do You Ever Muzzle Your Dog For Safety? *

Yes

No

Is Anyone In Your Family Afraid Of Your Dog? If So, Please Describe: *

How Does Your Dog Respond To The Following Situations?

When Approached While Eating: *

When Approached With Treat Or Toy: *

When Dog Is Scolded: *

When Dog Is Pushed Off Furniture Or Bed: *

When Dog Is Approached While Sleeping: *

To Strangers Outside Of The House: *

To People Entering House/Yard: *

To Children Or Infants: *

To Other Dogs In Your Home: *

While In Car To People Outside Of The Car: *

To Other Dogs Outside Your Home: *

Ever Aggrieve To Family Members? *

Yes

No

Has Your Dog Ever Bitten A Person? *

Yes

No

Has Your Dog Ever Been Reported To Animal Control For Biting? *

Yes

No