BEHAVIOR MODIFICATION HISTORY FORM

Please fill out the following to the best of your ability. The more information you are able to give us that pertains to your dog, the better we will be able to help you.

= mandatory field
LIVING ENVIRONMENT

HOW IS DOG EXERCISED/MAINTAINED

select all that apply:

DAILY WALKS

1 per day

avg length of each walk in minutes

PLAY SESSIONS

1 per day

TRAINING SESSIONS

1 per day

GROOMING SESSIONS

1

EXERCISE & ENRICHMENT

WHERE DOES DOG STAY WHEN S/HE IS LEFT ALONE?

select all that apply:

PERCENTAGE OF 24h DAY THAT PET SPENDS:

%

0

%

INSIDE

OUTSIDE

WHERE DOES DOG SLEEP AT NIGHT?

select all that apply select all that apply (we realize dogs move around overnight)::

LIVING ENVIRONMENT

SELECT YOUR LIVING SITUATION:

HAVE THERE BEEN HOUSEHOLD CHANGES SINCE ACQUIRING THIS PET?

LIVING SITUATION AND HOUSEHOLD CHANGES

HOUSEMATES: PEOPLE

NAME

RELATIONSHIP

AGE

OCCUPATION

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