Jones Animal Behavior: Canine History

Jones Animal Behavior

Canine Behavior History Form
Who may I thank for referring you to me?
Owner Information
Primary Owner/Contact Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Other Owner /Caregiver/Foster
Other Email
example@example.com
Other Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip
House color & parking instructions (for home visits)

Primary Pet Information
Primary or most concerning dog
Dog Name
Breed(s)
Age
Sex
Where did you get this pet?
What do you know about this pet's history?
How long has this pet lived with you?

Family Make Up

Describe all HUMANS in this DOG'S life:

Rows	Name	Age	Pronouns (or Gender)	Relationship	Interaction Frequency
1
2
3
4

Describe all other ANIMALS in this DOG'S life and not directly involved in your behavior concerns:

Rows	Name	Age	Sex	Species	Breed	Relationship	Interaction Frequency
1
2
3
4

Is this pet having conflict with any other pets?
Describe the first pet directly involved.
Breifly describe the conflict:
Describe the second pet directly involved.
Breifly describe the conflict:
Describe the third pet directly involved.
Breifly describe the conflict:

Health, Nutrition, Exercise
How many hrs/day is dog alone on average?
Describe type, amount, and intensity of exercise
Name of your vet clinic and the vet you prefer (if any).
Did your vet give you any recommendations for your concerns?
Date of most recent exam and notable comments

Submit proof of rabies vaccination via the button below (ensure image is clear and under 1MB. If you are unable to upload, please email it to info@jonesanimalbehavior.com)

Upload a File
Required for in-person sessions Cancelof
Any other relevant records

Upload a File

Cancelof

The Behaviors

There are questions/details later in the form specific to house soiling and to aggression
Describe the most concerning behavior you wish to address, if any
Describe the 2nd most concerning behavior you wish to address, if any
Describe the 3rd most concerning behavior you wish to address
Describe the 4th most concerning behavior you wish to address
Provide any additional behaviors and/or information.

Provide any additional behaviors and/or information.

Mentee Shadowing

Would you allow a mentee to shadow me in your appointment?

(Note: mentee will not give advice, participate, nor touch your pet unless instructed to do so by me and with your permission).

Agreement, Waiver & Release

Please

1. Review and sign the agreement

and

2. return to this page to SUBMIT this form
Should be Empty: