Intake & History Form — Kindred Companions LLC

CONSULTATION INTAKE FORM

This form allows the trainers at Kindred Companions to review a history for your pet prior to your scheduled consultation. Please take your time filling out this form and be as careful and detailed as possible.

Owner's Information

Name *

Name

First Name

Last Name

Email Address *

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Pet's Information

Pet's Name *

Breed *

Date of Birth *

Date of Birth

Best guess if adopted

MM

DD

YYYY

M/F/Altered? *

Please choose the sex of your dog and their reproductive status.

Pet's History

Date pet acquired:

Age of pet when acquired:

Pet acquired from: *

Medical Information

Veterinarian's Name *

Date of Last Visit

Date of Last Visit

MM

DD

YYYY

Reason for Last Visit

Date of Last Vaccinations *

Date of Last Vaccinations

MM

DD

YYYY

Vaccination(s) Given *

Current Health Problems/Medications

Past Medications/Treatments

Does your pet have any allergies, including food allergies?

Please be as specific as possible

Is your pet easily handled by the vet staff? *

Yes

No

Has he or she ever needed to be muzzled? *

Yes

No

Diet and Housetraining

What type of food do you feed your pet? *

What is your pet's feeding schedule? (Times/Amounts) *

What types of treats do you give your pet?

Has your pet ever become possessive or their food?

(if so, please describe)

Is your pet reliably house-trained/litterbox trained? *

Yes

Mostly (infrequent accidents)

No

Does your pet have access to the outdoors? *

Either a dog door, stays outdoors, etc.

Yes

No

Dogs Only: How often does your dog have access to the outdoors to relieve themselves?

Exercise

How often and what type of exercise does your pet receive? *

Please also include duration of exercise

Who is normally responsible for exercising your pet? *

What type of collar or harness and leash is being used? *

Has your pet ever become reactive to other pets or people on walks? *

Yes

No

If so, Please Describe:

Environment/Lifestyle

Please list the members of your household

Please include Name, Gender, Age, and their relationship to you for each member of the household on a separate line below

Who will be responsible for practicing the training with your pet? *

Does your pet "belong to" a particular family member or everyone

Do any of the household members dislike the pet? *

Yes

No

If so, please write in the reasons:

Are any household members afraid of the pet? *

Yes

No

If so, please write in the reasons:

Is the pet afraid of any household member? *

Yes

No

If so, please write in the reasons:

Where is your pet confined while you are not at home?

When you are home, is the pet allowed in the house *

Yes

No

If not, please write in your reasons:

If your pet is kept outdoors, would you like him to eventually be indoors?

Yes

No

Is your pet confined (crated, penned, etc) while you are home? If so, please write in typically how long and your reason: *

Where does your pet typically sleep at night? *

Approximately how many hours a day is your pet without human companionship? *

Do you have other pets living with you? *

Yes

No

If so, Please list below:

Name, type/breed, sex, spay/neuter?

Does your pet get along with the other household animals?

Yes

No

Does your pet play with toys, and if so, what are their preferences?

Please List 3 things you like about your pet:

Please list 3 things you do not like about your pet:

Training

How much training has your pet received?

No training as of yet

Trained them ourselves

Puppy Group Class

Basic Obedience Class

Intermediate Obedience Class

Advanced Obedience Class

Private Lessons

Sent to trainer

Dogs Only: If you and your dog attended a training class, did you complete the course?

Yes

No

Please check all the training methods used:

Food/Treats

Praise

Verbal Corrections

Physical Corrections

If you used a trainer, Please list the organization or trainer's name:

Please let us know how well your pet performs the following behaviors when asked:

Sit

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Down

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Come

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Walk Nicely on a Leash

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Leave it

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Give

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Wait

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Go to your place

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Quiet

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

Off (furniture or when they jump)

Never/Does not know the command

Seldom/Occasionally

About half the time

Often/Frequently

Always

If you checked off "Aggressive", "Fearful" or "Other", please describe below

What proceedures or training equipment have you tried to use to correct these problems?

In order of importance, what would you like help correcting?

Has your pet ever bitten anyone?

Yes

No

If so, please describe in detail below

Has medical attention been necessary (for animals or humans) because of any aggressive incident?

Yes

No

If yes, please explain below

What is your pet's usual reaction when a person they've never ever met before enters the home?

When was the last time someone unfamiliar to the pet entered your home

Is there anything else that you deem important for us to know?