Note: This is a very long questionnaire. You cannot save and continue, so please be ready to complete this form in one sitting.
Please answer all of these questions as honestly as possible. The more information I have, the easier it is for me to help you. Please do not withhold information out of embarrassment or fear of judgement. I need to know as much information as possible to solve your house training issues.
Owner Name *
Owner Name
Address *
Veterinary Clinic Phone Number
Veterinary Clinic Phone Number
Section 2
Section 3
Sex *
Is your pet spayed/neutered? *
Please select all that apply. *
Was the place clean? Were the animals clean/healthy? How many animals were there? Were the animals kept in cages/pens? Please provide as much detail as possible.
If you did not obtain your dog as a puppy, please continue to the next section.
At the place my puppy was raised, my puppy was...
At the place my puppy was raised, my puppy was...
Section 5
I feed my dog... *
I feed my dog... *
Section 6
When you're not home, where is your dog kept? *
Do you have a crate for your dog? *
Do you use the crate?
Does your pet ever potty in the crate? *
What is in your dog's crate? (Check all that apply) *
Section 7
Do you use potty pads, paper, or a litter box? *
When your dog goes outside to potty, do you... (check all that apply) *
How often do you take your dog outside to potty when you are home? *
Section 8
Has your dog ever been reliably house trained in the past?
If your dog was previously house trained but is now having accidents, please check any circumstances that apply.
My dog... (check all that apply) *
What kind of surface does your dog potty on in the house? (check all that apply) *
What kind of surface does your dog prefer to dog potty on outside? (check all that apply) *
When your dog urinates in the house, does he lift his leg? *
How often does your dog urinate in the house? *
How often does your dog defecate in the house?
My dog is most likely to have an accident... (check all that apply) *
How do you and/or family members react when your dog has an accident? *
Section 9
Does your dog eat his or another dog's stool?
Does your dog ever urinate, walk a few steps, then urinate again? *
Does your dog ever strain to urinate or defecate? *
Is there ever any blood in your dog's urine or stool? *
Does your dog have any loose stool or diarrhea? *
Has your dog ever been diagnosed with any of the following? *
Have you consulted your veterinarian about your dog's house training issues? *
Does your dog ever urinate when you or a friend/family member are petting him or reaching for him? *
Section 10
List names, breed, age and sex.