Name: Broadview Animal Hospital
Telephone: +1-
Price range: $$

Canine Behavior

This form is used to give the doctor a solid understanding of your pet’s behavior. Some questions are required (as indicated) and must be answered to complete the form. For best results, please try to answer all questions that are applicable. Please allow at least 30 minutes of time to complete this form as it is very detailed. If you need more time you can save and continue the form by selecting to do so at the very bottom of the form. Do not exit the form without saving or you will need to start it over again. Please note, this form is required to be completed in advance of your pet’s behavior consult appointment.

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Breed

Dog's Name(Required)

Date of Birth

Neutered / Spayed?(Required)

Sex(Required)

What location would you prefer to have the consult if available.(Required)

What is the main behavior problem or complaint?(Required)

How frequently does the main problem occur (how many times daily, weekly, monthly)?(Required)

Any additional problems?(Required)

Please list the additional problems.

How frequently do these additional problems occur?

What are your goals for this consultation?(Required)

Chronology of the Behavior Problem

When did you first notice the main problem (age of dog)?

When did it first become a serious concern?

In what general circumstances does your dog misbehave?

Has the problem changed in frequency? Please describe.

Has the problem changed in intensity? Please describe.

Has the problem otherwise changed?

Please describe the most recent incident in detail and indicate when it occurred.(Required)

Please describe the other significant incidents in detail and indicate when each occurred.

What have you do so far to try to correct the problem?(Required)

How do you discipline your dog for this behavior and for any other misbehaviors?(Required)

Have you previously enlisted the help of a trainer or veterinarian for this problem?

Please provide the trainer's or veterinarian's name and what you worked on with them.

What approaches have worked?

What approaches have NOT worked?

Home Environment

Do you have other people in the household?(Required)

Please list the people living in your household, and indicate their age and numbers of hours a day they are not at home on average.

How is your dog's relationship to the other people in the household (e.g. friendly, hostile, or fearful)? Please describe.

Do you have other animals in the household?(Required)

Please list all animals in the household, including the patient, in the sequence in which they were obtained.

If possible indicate species, breed, sex, age obtained, and current age of each.

How is your dog's relationship to the other animals (e.g. friendly, hostile, or fearful)? Please describe.

Have you moved since acquiring your dog?

How many times have you moved?

Has your household changed (i.e addition or loss of people or animals) since acquiring your dog?

Please describe how your household changed?

Dog's Backgroud

Why did you decide to get a dog?

Why did you choose this breed?

Where did you get this dog?

Have you owned dogs before?

Why did you choose this dog over the others? Please be specific.

Describe your dog's behavior as a puppy.

Do you have any information about the behavior of any littermates or the parents?

Please describe their behavior and indicate if a littermate or parent.

Has this dog had other owners?

How many other owners? Why was the dog given up?

At what age was your dog neutered or spayed?

Why was this done?

Where there any behavior changes after spay / neuter?

Please describe these behavior changes.

Has your pet ever been bred? Are you planning to breed?

Diet and Feeding

What do you feed your dog? Please be specific (brand name, flavor).

Has your dog's appetite changed recently?

How much and at what time(s) do you feed your dog?

Who feeds your dog?

Where is your dog fed? Where does your dog drink?

What is your dog's favorite treat?

Daily Schedule

Please describe a typical 24- hour day in your dog's life.

How does your dog behave with familiar visitors?

How does your dog behave with unfamiliar visitors (children or adults)?

How do you exercise your dog?

Which of the following do you have?

Fenced-in yard

Invisible fence

Both

Neither

Other

Please explain your "other" selection.

Is your dog housetrained?

Please explain your "other" selection.

Where does your dog sleep at night? Please be specific.

Have your dog's sleeping habit changed? Please explain.

Where is your dog when alone in the house?

Where is your dog when you have guests?

How does your dog behave when you return?

How does your dog behave while you are getting ready to leave the house?

Is your dog excessively frightened by any noise? Please explain.

Is your dog excessively frightened by anything else in the environment? Please explain.

Does your dog chase any of the following?

Child(ren)

Small dogs

Jogger / bicyclist / skateboarder

Vehicles

Other

Please select all that apply.

Please explain your "other" response.

How often does your dog do the following things?

Check all that apply

	Never	Occasionally	Sometimes	Always	Don’t Know
Follow you around the house?
Demand to be petted?
Become anxious at the sound of car keys?
Become anxious when you put on your coat or shoes?
Become agressive when you leave?
Exhibit other problem behaviors as you prepare to leave?
Bark or whine excessively within 30 minutes of your departure?
After you leave, activity decrease?
After you leave, appear depressed?
After you leave, have a loss of appetite?
Urinate or defecate in the home in your absence?
Have diarrhea, vomit, or lick excessively in your absence?
Exhibit an excessive greeting on your return (jumping, hyperactivity, barking for more than 2-3 mintues)?

What basic obedience training has your dog had?

Please explain your "other" response.

How old was your dog when obedience training started?

Who in the family is the primary trainer?

Does your dog have any awards or titles? If yes, please describe.

Has your dog had any hunting, herding, protection, attack, or Schutzhund training?

Please explain your "other " response.

Please rate your dog's activity level in general.

What type of collar or harness does your dog use?

Flat collar

Martingale collar

Choke collar

Prong collar

Electric collar

Head halter

Body harness

Other

Check all that apply.

Please explain your "other" response.

Which of the following does your dog do willingly?

Sit

Stay

Lie down

Heel

Fetch

Drop it

Leave it

Watch me

Come

Go to place

Other

Situations in which your dog is less likely to obey your commands.

Does your dog wear a muzzle happily?

Please explain your "other" response.

Date of most recent rabies vaccination?

Was the rabies vaccination good for 1-year or 3-years?

Please list any medications (including supplements) that your dog is currently taking.(Required)

Has your dog ever had any serious medical issues? Please explain.(Required)

Please list any previous behavior medications that have been tried.(Required)

Include dose, when each medication was started and stopped, why if stopped, and whether any improvement was noted.

Aggression Screen

Please indicate your dog's reaction to each of the listed scenarios below.

	Growl	Snarl / bare teeth	Snap / bite	Multiple reactions	No reaction	Not applicable
Pet dog
Hug dog
Kiss dog
Lift dog
Call off furniture
Push or pull off furniture
Approach when on furniture
Disturb while resting
Approach while eating
Touch while eating
Take dog food away
Take away treat
Take away toy or object
Approach when dog has an object, toy, or bone
Approach dog when near spouse
Enter room
Leave room
Reach toward dog
Put leash on or take off
Put collar on or take off
Groom or brush dog
Trim nails
Leash or collar correction
At veterinary hospital
Response to toddlers or babies
Unfamiliar adult approaches owner, dog on leash
Unfamiliar child approaches owner, dog on leash
Dog in house, sees people outside.
Response to other dogs while on leash.
Response to other dogs while off leash

Where are you on a scale of 1 to 5 as follows?(Required)

Is your dog aggressive towards people?(Required)

Please answer "Yes" or "No" to these characteristics of your dog's aggressive behavior.

	Yes	No
Attacks are sudden and surprising
Episodes appear unprovoked
The dog is abruptly docile after an episode
The dog appears “sorry” afterwards
The dog appears disoriented after an aggressive episode
Episodes are associated with a “glazed” or “absent” expression
I can usually tell what will set off my dog
The aggressive behavior is new and uncharacteristic

Has your dog bitten and broken skin?

Number of bites (that did or did not break skin)

Total number of episodes of aggression (growling, snapping, or biting).

Describe a typical episode (e.g. does dog growl, lunge or bite, and in what circumstance?).

If your dog is in the above situation 10 times, in how many of those times would he / she be agressive?

(e.g., all 10 times = 100%, just one time = 10%, etc.)

What parts of the body has your dog bitten? How severe where the injuries?

Who is/are the target(s) of aggression?

Did your dog bite as a puppy?

Please describe the dog bite as a puppy and how old was your puppy.

How old was your dog the first time he/she GROWLED at a person? What was the circumstance?

How old was your dog the first time he/she SNAPPED at a person? What was the circumstance?

Please add any other comments you would like to share with the doctor in the space below.

File Upload

Drop files here or

Max. file size: 256 MB, Max. files: 4.

If you have any videos or photos related to the problem behavior, please feel free to upload here. Please do not try to elicit any aggressive behavior for the purpose of obtaining a video. You may also email photos / videos to info@broadviewvet.com if you prefer.

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Behavior Canine

Canine Behavior

Chronology of the Behavior Problem

Home Environment

Dog's Backgroud

Diet and Feeding

Daily Schedule

Aggression Screen

Dover Location

Milton Location

Rochester Location