Service Dog Questionnaire

This questionnaire provides background history on your dog and your disability and service task needs before we meet or start training. This form is six pages. Please allow at least an hour to complete. We gather a detailed history before we meet to make your dog’s consult as helpful as possible.

Once you complete this form, remember that if you have more than one dog, you will also need to provide a short history on your other dogs with the Multiple-Dog Household Form.

SDiT BHH Service Dog in Training Behavior Health Habits Questionnaire

Background history before a service dog consult. An asterisk (*) indicates a required field. Please answer the questions as fully as you can. The more information you provide, the better prepared your trainer will be and the more useful the consult. Use the "extra space" sections if you have more to say.

Step 1 of 6 - Owner & Household Information

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Owner and Household Information
Owner Name*
First Last
Nickname? (Do you prefer to be called something other than above? If not, leave blank)
Email*
Date of your scheduled consult?*
Address (where you live)*
Street Address City State / Province / Region ZIP / Postal Code
Mailing address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
How may we reach you at this number? (check all that apply)*
- Text
- Call
- Voicemail
Secondary Phone
How may we reach you at this number? (check all that apply)
- Text
- Call
- Voicemail
Easiest way to reach you on short notice?*
Do you have preferred pronouns?
How did you hear of At Your Service?*
If referred, please give the name of the person who referred you
Why did you choose At Your Service?
Other household members*
List the NAME, AGE, and OCCUPATION or RELATIONSHIP of each of the other human members of the household. Include PCAs, home health aides, nannies, etc., who are often present. (If none, write "none.")
Other dogs*
Give the name, age, and breed of other dogs in the household. NOTE: IF YOU HAVE MORE THAN ONE DOG, YOU MUST ALSO FILL OUT THE "MULTI-DOG HOUSEHOLD" FORM. (If you only have one dog, write "none.")
Other Pets*
List the names, ages, and species of other pets (cats, gerbils, birds, horses, etc.). If none, write "none."
Your age/life stage*
Your primary occupation (or interest)

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Dog Information
Dog's Name*
Breed (or mix)*
Dog's date of birth (If unknown, give approximate age)*
Sex
Dog's size*
Date you acquired the dog*
How did you acquire the dog?*
Name of the breeder, rescue organization, or shelter (if known)

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Food and Health
How many times a day does the dog eat meals?*
What does your dog mainly eat?*
- Dry food (kibble)
- Wet (canned) food
- Homemade or raw food
- Other (give details in "more information")
Brand of food
Does your dog eat all their food when you put down the bowl?*
Does the dog get treats? What type and how often?*
Does your dog have food allergies or sensitivities?*
If yes, list foods to avoid:
Is your dog on any medications?*
Give name of medication(s) and condition they're prescribed for
Does your dog have any medical or health problems?*
If yes, describe health problem
Does the dog ever cry or whine, limp, or refuse a walk for no obvious reason?*
If yes, describe when that occurs
Does the dog often lick or chew paws or groin, rub face against things, or get ear infections?*
Name of your veterinary clinic*
Do I have your permission to contact them?*
If your dog sees a specific vet at this practice, please give their name
Approximate date of your dog’s last vet visit*
Extra space -- more information on Food/Health. (Use this space if you wish to elaborate on any questions above)