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Reactive Rover Workshop Questionnaire

Please complete and submit this form prior to the workshop.

Client Name:*

First

Last

Today's Date*

Dog's Name*

Dog's Breed:*

Dog's Age*

Dog's Sex*

Select valueMaleFemale

Would you consider your dog’s reactivity to be:*

Select valueMildModerateSevereExtreme

What are the primary triggers of your dog’s reactivity? Be as specific as possible.*

What is his threshold distance with a neutral dog in a calm environment? *

How old was your dog when you first noticed this behavior? *

What have you done to try to modify the behavior?*

Since you first noticed it, has the behavior:*

Select valueDecreasedIncreasedStayed the Same

Has your dog ever caused injury to another dog? *

Select valueYesNo

If Yes, what were the circumstances, and how severe were the injuries?*

Has your dog ever caused injury to a human? *

Select valueYesNo

If Yes, describe the circumstances, and how severe were the injuries?*

What are your goals for this workshop?*

What are your long term goals?*

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