DOG BODY CARE ASSESSMENT FORM



DOG BODY CARE ASSESSMENT FORM

Arizona Doggy Dude Ranch

Home of Canine Kinaesthetics™.

Sierra Vista, AZ 85650

cell 520 266-3124

Please email this form back to us at: maryna@

Date of profile:

Name:_______________________ Owner: __________________________

Breed:_

Born:_________Age:____________ Address:_________________________

Sex (N/S):____________________ _________________________

Color: _______________________ Phone: __________________________

Weight:

Sport/Use: Email:_________________________

Vet:_____________________________ Phone: _________________________

Length of time with owner:

Conditioning: ___ Low ___Moderate ___High ___Overweight ___Underweight

What Brand & type of Dog food do you use? __________________________

How much do you feed and on what schedule? ___________

Is your dog on any medications? No __ Yes ____

Please explain medication schedule.

Where does dog sleep:

Members of household:

Two Legged:

Four Legged:___

Does your dog interact well with your other pets? (If not, give us an explanation of any relationship problems between your dog and other pets.)

Do you live in a…. (Check one) ( ) Multi-level House ( ) Ranch House ( ) Apartment ( ) Loft ( ) Townhouse

( ) Other

Do you have a yard? (Y/N) Is your yard fenced? (Y/N) Do you have an invisible fence? (Yes or No)

Does your dog tolerate being crated? (Y/N)

HOW DID YOU FIND Dog Body Care?

Major Complaint or Issue: ______________________________________________________________

Has your dog had a recent surgery, if so, what:

History of past illnesses or surgeries: (Highlights)

Has your dog had a change in behavior? (Over what time period.)

Has your dog had a change in movement?

Has your dog had some kind of recent trauma or incident, physical or behavioral? If so, what?

Behavioral Checklist

Please place an X next to any of the problems below you’re having with your dog.

Not housebroken

Overactive and doesn’t settle down easily

Mounts people or objects

Urinates when excited/afraid

Jumps on people

Is aggressive toward dogs

Is aggressive toward people

Growls at family members when ___________________________________________

Nuisance barker/whiner

Play bites

Chews destructively on __________________________________________________

Doesn’t come when called

Bolts through open doors

Guards: toys-food-objects

Guards: space

Shy toward______________ ___ [Certain surfaces/openings/doors]

Stresses easily

Pulls on leash

Has bitten. (EXPLAIN who, why, severity of bite)

Sniffs at or eats off of countertops and tables

Jumps on furniture he shouldn’t

Separation anxiety

Digs in yard

Other _____________________________

Is there anything else we should know about you or your dog?

Movement Checklist: Please check any that apply. If you are unsure of an answer, just give me your best estimate. Photographs and/or video may clarify the answers. If there have been recent changes in any of these factors, please mark “recent” after.

Has difficulty sitting.

Sits crooked.

Has difficulty lying.

Always lies on one side.

Changes positions very rarely while lying.

Has difficulty standing up from a sit.

Has difficulty standing up from a down.

Has difficulty standing.

Stands with one leg cocked.

Has difficulty going up stairs.

Has difficulty going down stairs.

Has difficulty getting in the car. (What kind of vehicle and how high up?)

Has difficulty getting out of the car.

Walks crooked.

Trots crooked.

Runs crooked.

Changes in where the dog lies in a room.

Changes in how the dog interacts with other animals.

Changes in how close the dog gets to other animals.

Y/N Ifyou look straight at your dog, are his/her eyes at the same level?

Y/N If you look straight at your dog, is the distance from the middle of the crown of the head to the

ear, the same on both sides or different? Measurements from the middle to each ear?

If you look straight at your dog, what, if any differences do you see from one front leg to

the other? Using a tape measure, please measure your dog’s front leg two fingers

above the elbow on both sides. If it is a very small dog, one finger may be sufficient.

Left Leg Right Leg

If you look straight down on your dog while he/she is standing, what, if any differences

do you see in the shape of each shoulder to the other?

If you look straight down on your dog while he/she is standing, are there any zig zags in the

spine? If so, approximately where?

If you look straight down on your dog while he/she is standing, are there any zig/zags, whorls

in the hair coat down the spine? If so, approximately where?

If you look straight at your dog from behind, what, if any differences do you see from one

hind leg to the other? Using a tape measure, please measure your dog’s thigh 4"

above the hock. If it is a large dog, please measure 8" (or midthigh, but measure the same both sides) above the hock. If it is a small dog, please measure, three fingers

above the hock.

Left Leg Right Leg

Is your dog’s tail crooked? If so, where?

Body Assessment::

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Owner’s goal with dog:

Owner’s Homework:

I understand and agree that the information provided in this assessment is for the purposes of a general evaluation of body and movement factors that may be affecting my dog. This is not intended as a replacement for a veterinary consult, but to provide additional information to make any medical evaluation more complete.

I also understand and agree that genetics and environmental history (e.g.past experiences, lack of training, nutrition, health etc.) may affect my dog’s behavior. By submitting this assessment, I understand that further training and/or medical assessment may be necessary. This assessment is not intended to cure any aggression in my dog, and I further understand and assume all risks associated with owning and harboring a dog who may be aggressive. As a condition of receiving a DogBodyCare Assessment with Maryna Ozuna, I agree to waive all claims against Maryna Ozuna and DogBodyCare, the Arizona Doggy Dude Ranch, (ADDR), and to indemnify and hold Maryna Ozuna, DogBodyCare and ADDR, its officers, agents, and employees, harmless from any and all liability or claims I may have or that any other person or entity may have because of any death, bodily injury, personal injury, or because of any loss to property that may arise out of or in any way be connected with my dog’s assessment.

I understand that ADDR is a teaching facility and hereby consent to my dog’s being photographed or otherwise recorded, and give permission for the use of same, and waive any right, title or interest in any program, film or video taken at ADDR or in conjunction with DogBodyCare.

In the event of a dispute between the parties, the parties agree to submit the matter to binding arbitration.

I have read and agree to all the conditions above. Email return of this form and/or forwarding of photographs or video for assessment shall constitute full acceptance of the terms and conditions above.

Signature: ______________________________________Dated__________________

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