Expert Canine Intake Form
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Mobile Phone Number
Other Phone Number
Emergency Contact Name & Phone #
Names & ages of other people in the dog's home
Dog's Color/ Markings
Dog's Weight / Size
When did the dog join you?
Is the dog sterilized?
If sterilized, when & by which vet?
Any other dogs in the home? If so, please state age, gender, breed, sterilization, and vaccination status.
What if any foods or other items is the dog allergic to?
What kind and quantity of food does your dog eat for meals, and how often?
How often does your dog get treats, and what kind?
When was the dog's last vet visit, and for what?
When was the dog's last rabies vaccination, and by what vet?
Name & ph# of vet
When were the dog's last parvo & distemper vaccinations?
What else if anything is the dog currently vaccinated for?
What medications is the dog on currently? If none, what medications has the dog had in the past two years?
Has the dog ever been prescribed (whether taken or not) psychoactive medication? If so, which meds and for what conditions?
Have psychoactive medications ever been suggested or requested for your dog by you or by anyone else? If so, what was the response?
Have there been any recent changes in health or any recent injuries?
Has the dog had any surgeries, illnesses, or treatments in the past year or two?
Do you give permission for your dog's veterinarians to provide vet records and notes to us?
Please provide all of dog's vets' names and contact info.
If you answered no to the above, please provide us with a copy of current vaccination records and give your vets permission to confirm them with us via telephone.
Enter vet's name & telephone number above.
Where did you obtain this dog?
Friend or Family
Craigslist, Facebook, newspaper, or other ad
I found the dog (lost dog/stray/wandering)
What were the circumstances leading to your obtaining a dog?
What attracted you to this type of dog? And what attracted you to this particular dog?
Did the dog live with other owners, fosters, or anyone else before you? Please give all details possible.
Do you know what, if any, type of training (or handling) others used with the dog before you obtained the dog? Please provide details if known.
What types of handling & training do you use with the dog?
verbal corrections (e.g., "No!" "pssst!" scolding, etc.)
physical correction (e.g., leash pops, squirting, etc.)
prong collar/tightening collars
shock collar/vibrating collars
Please elaborate with details on your choices above.
What cues, if any, does the dog already know?
What is your current method for letting the dog know what behavior you want?
What is your current method for ensuring that desired behavior continues?
What is your current method for addressing undesirable behavior?
Have you taken the dog to any training previously? If so, when, for how long, and with whom?
Has your dog ever been confiscated or quarantined by animal control, or otherwise involved with animal control?
Please explain details.
Please describe the details of any behavior problems you or anyone else has experienced with the dog.
Use 'word pictures' to help us envision what happened.
Have any of these behaviors started just recently?
Has your dog ever bitten, tried to bite, lunged at, growled, or behaved aggressively toward any person or animal? If yes, please state which of these.
Use 'word pictures' to help us envision what happened.
Please describe the events leading up to any bites, attempted bites, lunging, cowering, or other behavioral concerns you have regarding the dog.
Again, use 'word pictures' to help us envision what happened.
Has the dog ever cowered, trembled, 'frozen,' attempted to avoid you or others, or seemed oddly uncomfortable? If yes, please state which of these
Please give details
Has the dog ever run away / escaped / gone missing?
How does your dog spend her/his days and evenings?
How many hours per day/night without you?
Where does s/he sleep (e.g., bedroom, couch, bed, crate, garage, kitchen, laundry room, yard, etc)
Is the dog ever crated, tethered, or otherwise confined? If so, for how long per day/night?
What does the dog most enjoy, and how often does the dog do that?
What do you most enjoy about the dog?
If you had to pick just one thing to change about your dog, what would it be?
If your dog had to pick one thing to change about you, what do you think it would be?
If you don't think s/he'd change anything about you, then what would s/he change about her/his lifestyle?
Have there been any sudden or recent changes in the dog's life / environment?
If you had to make up a creative name for your dog's personality type, what would it be & why?
If you had to make up a creative name for YOUR personality type, what would it be & why?
Yes, we know this is a bit silly. Humor us?
What issues, behaviors, &/or training would you like help with?
Basic Skills (e.g., Sit, Lie Down, Come, Walk on Leash, etc.)
Biting / Nipping
Drop it / Give
Feralization / Feral dog
Jumping on people
Loose Leash Walking (Not Pulling on Leash)
Wait at Door until Released
All Behavior Modification Foundations
All Positive Reinforcement Training Foundations
Please give details on your selections above, and feel free to add anything not mentioned.
What type of training program do you think might best suit your and your dog's needs?
Work for Me (Train My Dog For Me)
Work with Me (Guide me in Training My Dog)
Combination of both?
Not sure yet
What type of learner are you?
Visual (images, photos, graphs help more than words)
Auditory (Discussions, lectures, conversations help most)
Kinesthetic (Physical practice/experiences)
Reading/Writing (Writng notes, reading written words)
How did you hear of Expert Canine?
Anything else we should know or you wish to ask, please include it here.
Seriously! Don't be shy.
Do you prefer email, text, or phone for non-emergency communication?
What are the best days & times to reach you?
Sign with your fingertip or your mouse.
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