Behavior Questionnaire

Your Name

First NameLast Name

Email

example@example.com

Pet's Name

Breed

Date of Birth

Date

Sex

Spayed/Neutered

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

What is the main behavior problem or complaint?

Additional Problems?

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

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

When did it first become a serious concern?

In what general circumstances does the dog misbehave?

Has the problem changed in frequency? (please describe)

Has the problem changed in intensity? (please describe)

Has the problem changed otherwise?

Describe several examples in detail:

Most recent incident with date:

Second to last incident with date:

Third to last incident with date:

Other significant incidents:

What have you done so far to try to correct the problem?

How do you discipline your dog for this and for other misbehavior?

Please list the people, including yourself, living in your household. Please include ages of children

Please list all animals in the household including patient: (Include Name, species, breed, sex, age obtained, age now)

In what sequence were the above animals obtained? (Please number animals in the table above)

What is your dog's relationship to the other animals? (eg. friendly, hostile, fearful?) Please describe:

City/Town

Other

What type of house do you live in? Please describe

Have you moved since acquiring your dog?

How many times?

Has your household (people or animals) changed since acquiring your dog?

Please describe:

Why did you decide to get a dog?

Why did you choose this breed?

Where did you get this dog?

Where did you get this dog? - Details

Have you owned dogs previously?

Why did you choose this dog over the others?

If known: how many littermates? (Males, Females)

How many animals to choose from?

Was a temperament test performed?

Result:

Describe your dog's behavior as a puppy:

Do you have any news about littermate behavior? (Please describe)

Did you meet the parents?

If yes, please descibe their behavior:

Has this dog had other owners?

How many?

Why was the dog given up?

At what age was your pet neutered/spayed?

Why was this done?

Were there any behavior changes after neutering or spaying?

If your pet was "intact" has he/she ever been bred?

Are you planning to breed?

If you have an intact female, when was her last heat? Was it normal?

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

Has your dog's appetite changed?

How much do you feed? (Please be specific)

Who feeds the dog?

Location of feeding:

What's your dog's favorite treat?

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

How does the dog behave with familiar visitors?

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

How do you exercise your dog?

Is the dog free in a fenced yard?

Is your dog free to go in and out of yard unsupervised?

Is the dog tied outside?

Does the dog run free? Under what circumstances?

How do you play with your dog?

What toys does the dog have?

is your dog housetrained?

How was the dog housetrained?

Does your dog ever eliminate in the house?

Does your dog ever eliminate in the house? Where? Frequency? Any common triggers for this behavior?

Where does your dog sleep at night?

What is your dog's sleep pattern? Has there been any changes?

What arrangements do you have for your dog when no one is home?

How long are they typically alone?

Where is your dog when you have guests?

How does your dog behave while you are leaving the house?

How do you interact with your dog at this time?

How does your dog behave when you return?

How do you respond?

What basic obedience training has your dog had?

How did your dog respond to the training?

What type of training tools have you used (choke chains, prong collar, head halter, shock collars, treats)? Do you currently use any of these?

How old was the dog when obedience training started?

Who in the family is the primary trainer?

Does your dog have any awards or titles? (Please describe)

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

Out of 10 times, how many times will your dog obey you?

Out of 10 times, how many times will your dog obey family members?

Does your dog know any tricks? (Please describe)

Have you exhibited your dog in breed shows?

Does your dog jump on you or others without permission?

Does your dog paw at you or others?

Does your dog lick you or others?

Does your dog mount you or others? If yes, Whom?

Does your dog mount other animals or objects?

Does your dog bark at you? If yes, How do you respond?

Does your dog bark at others? Growl at others?

Does your dog bark at other times?

What is your dogs activity level in general?

Is your dog on any medication now, for this or other problems?

Has your dog been on medication in the past?

Date of the most recent rabies vaccination:

Did you notice a change in behavior after rabies vaccine was given?

Pet dog

Hug dog

Kiss dog

Lift dog

Call off furniture

Push/Pull off furniture

Approach on furniture

Disturb while resting/sleeping

Approach while eating

Touch while eating

Take dog food away

Take human food away

Take water dish away

Take rawhide

Take biscuit/cookie

Take real bone

Take toy/object

Approach when dog has any toy/object/bone

Verbally punish

Physically punish

Visual threat

Speak to dog (normal tone)

Stare at dog

Bend over dog

Push on shoulders or back

Approach dog near significant other

Enter room

Leave room

Reach toward dog

Leash restraint

Collar restraint

Scruff restraint

Put leash on/take off

Put collar on/take off

Bathe dog

Towel dog

Groom/brush dog

Dog at groomers

Trim nails

Leash/collar correction

Response to "sit"

Response to "down"

Dog at veterinary clinic

Unfamiliar adult enters house or yard

Unfamiliar child enters house or yard

Familiar adult enters house or yard

Response to toddlers/babies

Dog in response to tollbooths/gas stations

Unfamiliar adult approaches, dog on leash

Unfamiliar child approaches, dog on leash

Dog in house, sees people outside

Response to other dogs while on leash

Response to other dogs, while not on leash

Where are you on a scale of 1 to 5 as follows

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 afterwards

Episodes are associated with a "glazed" or "absent" expression

I can usually tell what will set off my dog

The aggressive behaviour is new and uncharacteristic

Has your dog bitten and broken skin?

Number of bites that broke skin

Total number of bites (that did or did not break skin)

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

Describe typical episode (eg. does dog growl, lunge or bite, and in what circumstance)

If the dog is in the above situation 10 times, in how many of those times is aggresion seen (eg. all=100%, just one=10%, etc.)

What parts of the body has the dog bitten and how severe were the injuries?

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

Did your dog bite as a puppy?

If yes, please describe, including age

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 or bit at a person?

What was the circumstance?

How much time are you willing to spend working with your dog daily/weekly?