Jemi Hodge & Associates, Inc.
Date Called: ______Trainer Assigned: ______
Date Initially Booked: ______Amount Quoted: ______
Date Follow Up Booked: ______Amount Paid: ______
OWNER BACKGROUND
Name: ______Email:______
Address: ______
City:______State: ______Zip: ______
Phone: (H) ______(W) ______(C) ______
Other family members in household: ______
Veterinarian: ______Referred by: ______
PET HISTORY
Name: ______Age: ______Sex: ______Breed: ______
Spayed or Neutered? o Yes o No; If no, do you plan to? o Yes o No; If yes when? ______
How long have you had your pet? ______; Where did you get your pet? ______
What type of training has your pet had (formal or informal)? ______
______
What type of food to you feed your pet and how often? ______
Any other pets in the household? o Yes o No; If yes, type and how many: ______
If other family pets, do they have any issues? o Yes o No; If yes, describe: ______
______
How have your corrected unwanted behavior in the past and what were the results? ______
______
Is your pet on any medication or has been diagnosed with medical problems? Please list: ______
______
Where does your dog sleep? ______
Where does your pet spend the most time? o Inside or o Outside of the house?
Do you have a fenced in yard? o Yes o No; What type of fence and how high? ______
BEHAVIORAL ISSUES:
o Yes o No Does your pet know any commands, if yes which ones? ______
o Yes o No Does your pet ignore you?
o Yes o No Does your pet come to you when called?
o Yes o No Does your pet jump up on furniture? Is it allowed? o Yes o No
o Yes o No Does your pet jump up or climb up on counters or table?
o Yes o No Does your pet jump up on guests or other family members?
o Yes o No Does your pet beg for food?
BEHAVIORAL ISSUES (con't):
o Yes o No Does your pet have accidents in the house and if so, how often? ______
o Yes o No Does your pet lift leg to mark in the house?
o Yes o No Does your pet run laps in the house?
o Yes o No Does your pet bolt out of doors or gates?
o Yes o No Does your pet dig holes in your yard?
o Yes o No Is your pet destructive inside or outside the house? Explain: ______
______
o Yes o No Is your pet shy or timid around other people? Explain: ______
______
o Yes o No Is your pet afraid of thunderstorms or other loud noises? Explain: ______
______
o Yes o No Is your pet o Pushy o Clingy o Needy o Mouthy (check applicable)?
o Yes o No Is your pet a thief with food or other objects?
o Yes o No Is your pet possessive of food or other objects?
o Yes o No Is barking an issue?
o Yes o No Does your pet pull, tug, drag, or lunge while on a leash?
o Yes o No Does your pet growl during play?
o Yes o No Does your pet show aggression towards other animals?
o Yes o No Has your pet shown aggression towards people?
o Yes o No Does your pet nip at hands, feet, ankles, etc?
o Yes o No Has your pet ever bitten? If yes, how many times? ___ Medical care required? o Yes o No
o Yes o No Are you crate training your pet? If yes, what type of crate? o Wire o Plastic
How often and how long is your pet crated while you are at home? ______
How long is your pet crated while you are not at home? ______
o Yes o No Does or dog ever whine, bark, or howl when crated or confined?
OTHER:
What are the top three problems you would like to see solved?
1. ______
2. ______
3. ______
o Yes o No Would you be interested in signing up for group classes?
COMMENTS: ______
______
______
May 2011