New client in-depth history form

ADAPTIVE ANIMALS

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IN-DEPTH HISTORY FORM FOR NEW CLIENTS

Consultant's name *

Consultation for what species of animal? *

dog cat other

Please note that all animals will be referred to as pets in this survey.

GENERAL INFORMATION

Name *

First

Last

Other family members *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Pet name *

Breed *

Age *

Sex *

Female Male

Neutered? *

Yes No

Other animals in the home *

HISTORY

Are you contacting us for a legal reason (bite report, lawsuit)? *

yes no

What is the primary problem you are experiencing with your pet? *

How often does the problem occur? *

When did the problem begin? How long has it been going on? *

How long have you owned this animal? *

How old was the animal when you got it? *

From whom did you get the animal? (breeder, humane society, rescue, pet store, private sale, etc). Please describe briefly. *

What do you know about the animal's history before you became the owner? *

Do you know of any pre-existing issues or traumatic events in the animal's life? Describe them here briefly. *

Have there been any recent life changes (medical, social, living arrangements)? *

What measures have you taken to manage the problem before contacting us? *

VETERINARY INFORMATION

Who is your veterinarian? *

Did you consult with your veterinarian about the behavior issue? *

Yes No

What was your veterinarian's assessment and recommendation? *

Is your pet currently taking medication? If so, please list which medications and for how long. *

Answer "no" if you pet is not currently taking medications.

INCIDENTS
Describe up to FOUR recent and/or major incidents that illustrate the problem you are experiencing with your pet. Please explain the following information in the spaces provided: (1) When did the incident happen? If you don't remember the exact date, please estimate to the best of your knowledge. (2) What events lead up to the incident? (What were you and your pet doing? Where did it occur? What people or animals were around? etc.) (3) How did you react to it and manage the incident? (4) Did it result in injury to another animal or human? If so, how extensive were the injuries?

Incident #1
(required)

Incident #1-Date (mm/dd/yy) *

Incident #1-Did it result in injury to an animal or human? *

yes no

Incident #1-What happened? *

Incident #1-What events led up to the incident? *

Incident #1-How did you react to and manage the situation? *

Incident #1-Describe any injuries. *

Incident #2

Incident #2-Date (mm/dd/yy) *

Incident #2-Did it result in injury to an animal or human? *

yes no

Incident #2-What happened? *

Incident #2-What events led up to the incident? *

Incident #2-How did you react to and manage the situation? *

Incident #2-Describe any injuries. *

Incident #3

Incident #3-Date (mm/dd/yy) *

Incident #3-Did it result in injury to an animal or human? *

yes no

Incident #3-What happened? *

Incident #3-What events led up to the incident? *

Incident #3-How did you react to and manage the situation? *

Incident #3-Describe any injuries. *

Incident #4

Incident #4-Date (mm/dd/yy) *

Incident #4-Did it result in injury to an animal or human? *

yes no

Incident #4-What happened? *

Incident #4-What events led up to the incident? *

Incident #4-How did you react to and manage the situation? *

Incident #4-Describe any injuries. *

CURRENT ROUTINES

Activities. How does your pet spend a typical day?

Daily routine (please describe) *

How much and what kind of training? *

How much time and nature of socializing/interacting with other animals and/or people *

How much time spent alone? Please describe. *

Food. What is your animal's feeding routine?

What do you feed your pet? Please be specific. *

What is the daily feeding schedule? *

Does your pet also get treats? What kind and how often? *

Please type "no" if you do not supplement meals with treats.

Does your pet have any diet restrictions or food allergies/sensitivities? *

Please type "no" if your pet does not have any diet restrictions.

ADDITIONAL REMARKS

Is there anything else you would like us to know? *

THANK YOU!

Submit

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Home
Services
Expert witness
Links
Blogs
Bio

IN-DEPTH HISTORY FORM FOR NEW CLIENTS

GENERAL INFORMATION

HISTORY

VETERINARY INFORMATION

Incident #1(required)

Incident #2

Incident #3

Incident #4

CURRENT ROUTINES

Activities. How does your pet spend a typical day?

Food. What is your animal's feeding routine?

ADDITIONAL REMARKS

THANK YOU!

Incident #1
(required)