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Broadview Animal Hospital

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Behavior Canine

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)
Email(Required)

Chronology of the Behavior Problem

Home Environment

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

Dog's Backgroud

Diet and Feeding

Daily Schedule

Which of the following do you have?
Does your dog chase any of the following?
Please select all that apply.
Check all that apply
NeverOccasionallySometimesAlwaysDon'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 type of collard or harness does your dog use?
Check all that apply.
Which of the following does your dog do willingly?
Include dose, when each medication was started and stopped, why if stopped, and whether any improvement was noted.

Aggression Screen

GrowlSnarl / bare teethSnap / biteMultiple reactionsNo reactionNot 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
YesNo
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
(e.g., all 10 times = 100%, just one time = 10%, etc.)
Drop files here or
Max. file size: 128 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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