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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.

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= mandatory field
LIVING ENVIRONMENT
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HOW IS DOG EXERCISED/MAINTAINED

select all that apply:
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DAILY WALKS

1 per day
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avg length of each walk in minutes

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PLAY SESSIONS

1 per day
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TRAINING SESSIONS

1 per day
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GROOMING SESSIONS

1

EXERCISE & ENRICHMENT

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

select all that apply:

SPECIFY OTHER WAY YOUR DOG IS KEPT WHEN LEFT ALONE:

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PERCENTAGE OF 24h DAY THAT PET SPENDS:

%

0

%

INSIDE

OUTSIDE

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WHERE DOES DOG SLEEP AT NIGHT?

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

LIVING ENVIRONMENT

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SELECT YOUR LIVING SITUATION:

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HAVE THERE BEEN HOUSEHOLD CHANGES SINCE ACQUIRING THIS PET?

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HOW? 

select all that apply:

LIVING SITUATION AND HOUSEHOLD CHANGES

HOUSEMATES: PEOPLE

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NAME

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RELATIONSHIP

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AGE

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OCCUPATION

time(s) per

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time(s) per

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time(s) per

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