Human Reactivity Intake Name * First Name Last Name Dog's Name / Age / Breed / Sex * Bite Levels Has your dog's mouth made contact with a person during any of the incidents? * Yes No Number of Bite Occurances * (If none please put 0) If yes, what is the worst result that has occured? * Not Applicable 1) Snap 2) Contact with no damage 3) 1 to 4 shallow punctures 4) 1 to 4 deep punctures 5) Deep bi-directional tears 6) Multiple level 4s and 5s 7) Mutilation Incident Description Describe the incident(s) you are concerned about * Location(s), people involved Was the person * Known to the dog A Stranger to the dog Have you noticed anything similar about the situations or people involved across the incidents? (examples: all men, all at the front door, all while on leash, etc.) * Have you noticed any escalation or change in your dogs behavior over time? * Stress / Warning Signs Which of these behaviors have you noticed occur just before an incident? * Freeze Bark Lunge Growl Snap Muzzle Punch Bite Resource Guarding Could any of the incidents involved the dog protecting: * Toys or Items Food Treats or Chews Favorite Spot Favorite Person none Handling Did any of the Incidents involve the Dog being Touched (or) * Paws Tail Ear Muzzle Head Rump Back Neck Describe the person involved in the incident * Age, male, female, Clothing, Hats, glasses, unusual behavior, changing positions, hidden from dogs view, carrying something, etc Sudden Environmental Contrast Did any of the incidents involve someone... * Changing positions (sit to stand, Stand to sit, etc) Up High Reentering the room Partially Obstructed Carrying something Movement Sensitivity Did any of the incidents involve * Joggers Bicycles skateboards Children Running Children Screaming Strollers none Thank you!