Annual Client Questionnaire

Client's Name *
Client's Name
Name of person completing questionnaire
Name of person completing questionnaire
Phone *
Phone
Address *
Address
Service Dog Equipment
About Your Service Dog
Is your service dog still in active service?
Are there any new or unexpected assistance behaviors that your has dog learned in the last year?
Is your dog working to your expectations?
Please indicate if your dog has exhibited any of the following behaviors
Have any insurance claims or reports to the police been filed in regards to an incident caused by your dog?
Does your dog demonstrate adverse body language or have difficulty while:
Being dressed or groomed
Traveling
(entering and exiting buildings, riding in car, plane, train, etc.)
Being in crowded, noisy environments
Being around other dogs
Being around children
Being in nature with birds and/or critters present
Please indicate which cue/behavior categories you utilize regularly with your service dog and whether or not they demonstrate proficiency (service dog responds to cues 90% of the time or more).
Proficient: Service Dog responds to cues 90% of the time or more Not-Proficient: Service Dog responds to cues less than 90% of the time
Balance Cues
(e.g. brace)
Retreival Cues
(e.g. get it, bring)
Safety Cues
(e.g. get help, find person's name)
Positional Cues
(eg: heel side, follow)
Social Cues
(e.g. visit, high five)
Autism Related Cues
(e.g. emergency down, brace/squish)
PTSD Related Cues
(e.g. respond to triggers by resting head or licking)
Dog's Health
Does your dog have any medical problems that would affect his/her ability to be a working service dog?
Is your dog's license current?
Are your dog's vaccinations up to date?
Do you have auto insurance?
Do you have veterinary insurance?
Dog's current weight (see below chart)
Do you expect your service dog to retire in the next 12 months?