Dog Owner NameFirstLastDog's NameBreed AgeSexMaleFemaleDesexedYesNoWhere did you get your dog?BreederRescue / shelterRehomed from previous ownerOtherIf your dog is a rescue, is their history known?YesNoNot sureIf the dog is a rescue, give brief details of the history (if known)What age was the dog when brought home?Young puppy (8-16 weeks of age)Older but under 1 (17 weeks - 1 year old)1 - 2 years oldOver 2How was the dog socialised within the first 16 weeks of age?Adequate socialisation and exposureLimited socialisation and exposureNo socialisation nor exposureNo known historyWebsite URL*What does the dog react to? (Select all that apply)Other dogsPeopleChildrenBicyclesRunnersCarsOther animalsSounds / noiseTVOtherNo specific triggerWhere does the reactivity happen? (Choose all that apply)On walks, both on and off leashOnly when on a leashAt homeAt the parkWhen visitors arriveWhen hears soundsFence reactivityAt the vetAt workOtherWhat age did the reactivity first start?Young puppy (8-16 weeks of age)Between 6 - 12 months of age1 - 2 years oldOver 2 years oldNot knownAt approximately what distance does your dog begin reacting?Very close (in the dog's personal space)Within a few metresAcross the streetAt sight of triggers, no matter the distanceWhat type of reactivity is itReacts to all trigger no matter the typeSelective; certain type of triggersSituational; only in certain situationsIs the dog sound sensitive?Yes, both at home and outdoorsYes, but only at homeNoWere there any negative experiences with triggers?YesNoNot knownIf yes, describe brieflyWas there free play at parks, before or after reactivity:Yes, regularlyNoOccasionallyNot knownDoes the dog go or used to go to a dog daycare?Yes, regularlyOccasionallyNoNot knownCan the dog eat outside? (high-value treats)YesYes, but struggles (need to be prompted with the smell)NoCan the dog play outside?YesNoCan the dog play and eat at home?Yes, bothCan eat but not playIs the dog on medication for behavioural issues?YesNoIf yes, describe briefly Has the dog ever bitten a person or another dog?NoYes — another dogYes — a personIf yes, please briefly describe what happenedHow often is the dog walked?Once per dayTwice per dayA few times per weekRarelyWhat is the duration of daily exercise?Up to 30 minutes30 - 60 minutes1h - 1.5hOver 2hEnrichment daily routine (choose all that apply)TrainingPlayingTreat ToysChewsOccasionallyNoDoes the dog play fetch?Yes, loves it!Yes, but not obsessiveNoTrainer Assessment: Does the dog exhibit any obsessive behaviours?YesNoIf yes, describe brieflyTrainer Assessment: Is the dog anxious?YesNoTrainer Assessment: Is the dog over-aroused?YesNoTrainer Assessment: What behaviours does the dog display during a reactionBarkingHuffing (pre-bark)WhiningGrowlingPulling toward the triggerLungingSnappingHiding / avoidance / jumping on the owner (attention seeking)ShakingFreezingTense bodyFixatingLoses appetiteOtherTrainer Assessment: How intense are the reactions?Mild — can easily disengageModerate — hard to redirectSevere — completely fixated / uncontrollableSend
