Canine Pet Behavior Form

Preferred Method of Contact*

Phone

Either

Patient Information

Pet's Name

Breed

Age

Sex/Status (neutered, spayed, intact)

How long have you had your dog?

Where did you get your dog from?

Has your dog had other owners? If so, how many? Please briefly describe their other living situations or owners.

Please explain why your dog was previously relinquished, if applicable.

Why did your family pick this pet?

What was your animal’s early socialization experience like (3 weeks-6 months old)? If not known, please write “unknown”.

Have you considered euthanasia or rehoming your pet prior to your visit to us?

Environmental

How many people live in the house? Please list all members and their age.

Are there any children under the age of 18 who come to visit often?

Have there been any significant changes to your household’s routine or schedule in the past 6 months?

If you feel the relationship between your dog and any particular person is important, please describe.

Tell us about your dog’s environment (select all that apply):

Leash walked

Dog park

Solid wood fence

Chain link, iron, or aluminum fence

Tie out

Play in fenced yard

Electric fence

Spends most time indoors

Spends most time outdoors

Dog door/free choice access

How many play or training sessions does your dog get per day?

Applicable only to households with multiple pets.
Does your pet:

Sleep with your other pets

Groom your other pets

Play with your other pets

If applicable, list other animals in the household and describe their relationship with the patient:

Please include a brief description of your daily routine with your pet:

Medical

Please describe any significant medical illnesses, treatments, and outcomes:

What does your pet eat?

Does your pet have any allergies or food sensitivities?

Has your pet had any medication reactions?

Please list any previously diagnosed medical conditions:

Please list any medications your pet is currently taking:

Please list any medication reactions your pet has had before:

Please check all previous treatments tried:

Acepromazine

Adaptil diffuser

Anxitane

Diazepam

Rescue remedy

Trazodone

Acupuncture

Adaptil spray

Cbd oil or treats

List all medications or supplements your pet is currently taking:

Does your dog lick excessively?

Does your dog experience any vomiting, diarrhea, constipation, decreased appetite, excessive licking, lip licking? If so, please describe the following:

Behavior Problem

What are your goals for this appointment?

Please describe the primary concern for this appointment, with as much detail as possible:

What age did this problem start?

How frequently is this problem happening?

> 1x/day

1x/day

3-6x/week

1-3x/week

<1x/week

Is there another concern that you wish to address? If yes, please describe:

Have you ever worked with a dog training professional with this pet?

Please list the trainer and what the focus of this training was + type of methods used:

Are you planning to continue to work with the dog training professional listed above?

Have you used any of the following methods before? Select all that apply:

E-collar

Prong collar

Gentle leader

Treats

Muzzle

Clicker

Is your pet house-trained? Do they ever have accidents?

What behaviors does your pet currently know?

What behaviors would you like your pet to know?

What types of rewards/motivations does your pet enjoy? Select all that apply:

Treats/food

Praise/petting

Toys

Other

How much time do you have to devote to training daily?

Less than 5 minutes

5-10 minutes

15-20 minutes

30 minutes

30+ minutes

Sleep Behaviors

Does your pet sleep through the night?

Have you noticed any sleep pattern changes in the past 3-6 months?
If yes, please describe:

Does your pet take naps during the day when you are home?

Aggression

If your pet has shown aggression, please fill out this section. If not, go to the next section.

Are there any people in your household, or, who regularly come to visit that are at greater risk of illness or injury (elderly, children, illnesses)?

Has your dog ever bitten a person?

If yes, please describe the bite(s) and the severity:

Has your dog ever bitten a dog?

If yes, please describe the bite(s) and the severity:

Were any bites reported to public health authorities?

Has there been any legal action as a result of your dog’s behavior?

Who is your dog aggressive towards? Please check all that apply:

Familiar adults

Familiar dogs

Familiar children

Familiar cats

Unfamiliar adults

Unfamiliar dogs

Unfamiliar children

Unfamiliar cats

Wild animals outside the home

Veterinarian

Groomer

Other

When is your dog aggressive (what triggers their aggression)?

What does your dog look like when aggressive? Select all that apply:

When visitors enter the home:

Jumps

Tries to escape

Growls

Barks

Runs away

Hides

Lunges

Bites

Other

Please share any additional information that you would like to share about how, when, or to whom your pet is aggressive.

Storms/Sounds

If your dog exhibits fear or anxiety during storms or loud noises, please fill out this section. If not, proceed to the next section.

What sounds frighten your dog?

What does your dog do when they are frightened by a sound?

How long after a sound does it take your dog to calm down entirely?

When did this sensitivity to sounds start?

Please add any additional information that you would like to share:

Separation Behaviors

If your dog exhibits anxiety or distress when left alone please fill out this section. If not, go to the next section.

Does your dog follow you around the house constantly?

How does your dog act when you prepare to leave? Please describe:

How does your dog behave when you return? How intense is their reaction, and how long does it persist?

Where is your dog when you are not home?

What does your dog do when you are not home?

Does your dog exhibit the same behavior every time that you depart?

Does your dog exhibit the behavior only when alone?

Does your dog exhibit the behavior when a particular person leaves, but not another? If yes, who?

Please add any additional information that you would like to share:

Displacement/Compulsive/Repetitive Behaviors

If your dog exhibits any of the behaviors below, please fill out this section.

Does your dog do any of the following?

Stare at lights/shadows

Run in circles

Chase tail

Fly snapping

Other

Canine Pet Behavior Form

Preferred Method of Contact*

Patient Information

Pet's Name

Breed

Age

Sex/Status (neutered, spayed, intact)

How long have you had your dog?

Where did you get your dog from?

Has your dog had other owners? If so, how many? Please briefly describe their other living situations or owners.

Please explain why your dog was previously relinquished, if applicable.

Why did your family pick this pet?

What was your animal’s early socialization experience like (3 weeks-6 months old)? If not known, please write “unknown”.

Have you considered euthanasia or rehoming your pet prior to your visit to us?

Environmental

How many people live in the house? Please list all members and their age.

Are there any children under the age of 18 who come to visit often?

Have there been any significant changes to your household’s routine or schedule in the past 6 months?

If you feel the relationship between your dog and any particular person is important, please describe.

Tell us about your dog’s environment (select all that apply):

How many play or training sessions does your dog get per day?

Applicable only to households with multiple pets. Does your pet:

If applicable, list other animals in the household and describe their relationship with the patient:

Please include a brief description of your daily routine with your pet:

Medical

Please describe any significant medical illnesses, treatments, and outcomes:

What does your pet eat?

Does your pet have any allergies or food sensitivities?

Has your pet had any medication reactions?

Please list any previously diagnosed medical conditions:

Please list any medications your pet is currently taking:

Please list any medication reactions your pet has had before:

Please check all previous treatments tried:

List all medications or supplements your pet is currently taking:

Does your dog lick excessively?

Does your dog experience any vomiting, diarrhea, constipation, decreased appetite, excessive licking, lip licking? If so, please describe the following:

Behavior Problem

What are your goals for this appointment?

Please describe the primary concern for this appointment, with as much detail as possible:

What age did this problem start?

How frequently is this problem happening?

Is there another concern that you wish to address? If yes, please describe:

Have you ever worked with a dog training professional with this pet?

Please list the trainer and what the focus of this training was + type of methods used:

Are you planning to continue to work with the dog training professional listed above?

Have you used any of the following methods before? Select all that apply:

Is your pet house-trained? Do they ever have accidents?

What behaviors does your pet currently know?

What behaviors would you like your pet to know?

What types of rewards/motivations does your pet enjoy? Select all that apply:

How much time do you have to devote to training daily?

Sleep Behaviors

Does your pet sleep through the night?

Have you noticed any sleep pattern changes in the past 3-6 months? If yes, please describe:

Does your pet take naps during the day when you are home?

Aggression If your pet has shown aggression, please fill out this section. If not, go to the next section.

Are there any people in your household, or, who regularly come to visit that are at greater risk of illness or injury (elderly, children, illnesses)?

Has your dog ever bitten a person?

If yes, please describe the bite(s) and the severity:

Has your dog ever bitten a dog?

If yes, please describe the bite(s) and the severity:

Were any bites reported to public health authorities?

Has there been any legal action as a result of your dog’s behavior?

Who is your dog aggressive towards? Please check all that apply:

When is your dog aggressive (what triggers their aggression)?

What does your dog look like when aggressive? Select all that apply:

When visitors enter the home:

Please share any additional information that you would like to share about how, when, or to whom your pet is aggressive.

Storms/Sounds If your dog exhibits fear or anxiety during storms or loud noises, please fill out this section. If not, proceed to the next section.

What sounds frighten your dog?

What does your dog do when they are frightened by a sound?

How long after a sound does it take your dog to calm down entirely?

When did this sensitivity to sounds start?

Please add any additional information that you would like to share:

Separation Behaviors If your dog exhibits anxiety or distress when left alone please fill out this section. If not, go to the next section.

Does your dog follow you around the house constantly?

How does your dog act when you prepare to leave? Please describe:

How does your dog behave when you return? How intense is their reaction, and how long does it persist?

Where is your dog when you are not home?

What does your dog do when you are not home?

Applicable only to households with multiple pets.
Does your pet:

Have you noticed any sleep pattern changes in the past 3-6 months?
If yes, please describe:

Aggression

If your pet has shown aggression, please fill out this section. If not, go to the next section.

Storms/Sounds

If your dog exhibits fear or anxiety during storms or loud noises, please fill out this section. If not, proceed to the next section.

Separation Behaviors

If your dog exhibits anxiety or distress when left alone please fill out this section. If not, go to the next section.

Displacement/Compulsive/Repetitive Behaviors

If your dog exhibits any of the behaviors below, please fill out this section.