Behavioral History Questionnaire
Please complete and submit this questionnaire at least three days prior to our appointment.
Please note: Methods of payment accepted are cash or check only on day of session. PayPal or Venmo also accepted.
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of dog:
Breed:
Sex
Female
Male
Spayed
Neutered
Breed:
Date of Birth
What is the main behavior problem or complaint?
Additional problems
How frequently does the problem (or problems) occur (how many times daily, weekly, monthly or other):
Rows
Problem
Frequency
Main Problem
Other Problem
Other Problem
When did you first notice the main problem (age of the dog)?
When did it first become a serious concern?
In what general circumstances does the dog misbehave?
Has this problem changed in frequency? (please describe)
Has this problem changed in intensity? (please describe)
Has this problem changed otherwise?
Please describe several examples in detail:
Rows
Problem
Date
Most recent incident
Second to last incident
Third to last incident
Other significant incidents
What have you done so far to try to correct this problem?
How do you discipline your dog for this and other misbehavior?
Home Environment
Please list the people, including yourself, living in your household. Please include ages of any children.
Rows
Name
Hours Away From Home
Name
Name
Name
Name
Name
Please include all animals in the household including patient. Also indicate in what sequence the animals below were obtained.
Rows
Name
Species
Breed
Sex
Age Obtained
Age Now
Sequence Obtained
Name
Name
Name
Name
What describe your dog's relationship to the other animals (e.g. friendly, hostile, fearful)? Please describe.
What type of area do you live in?
City/Town
Suburbs
Rural
Have you moved since acquiring your dog?
No
Yes
Has your household changed (people or animals) since acquiring your dog?
No
Yes
If yes, please describe.
Dog's Background
Where did you get this dog?
Rescue Group
Breeder - referral
Breeder - other
Friend
Stray
Other
Name of Rescue Group or Breeder where dog was obtained.
If known, how many littermates?
How many animals to choose from?
Why did you choose this dog over the others?
Do you have any information about the littermate(s) behavior?
Did you meet the parents?
Yes
No
Has this dog had other owners?
Yes
No
If yes, how many?
If yes, why was the dog given up?
Diet and Feeding
What do you feed your dog?
Who feeds the dog?
Where does your dog eat?
What are your dog's favorite treats?
Does your dog have any food allergies?
Yes
No
If yes, please list foods.
Please describe a typical 24-hour day in your dog's life
How do you exercise your dog?
Is the dog free in a fenced yard?
Does the yard have an electric (aka invisible) fence?
Yes
No
Where is the dog when alone in the house?
Where is the dog when you have guests?
What type of training has your dog had?
None
Trained at home
Started training classes but didn't finish
Graduated training class once
Graduated training class two or more levels
Private training
Other
What is your dog's activity level in general?
Low
Average
High
Excessive
Other
Name of Dog's Veterinarian
Is the dog current on it's vaccines?
Yes
No
Please upload dog's shot record.
Browse Files
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Is your dog on any medication now, for this or other problems?
Has your dog been on medication in the past?
Aggression Screen
Rows
Growl
Snarl/bare teeth
Snap/bite
No reaction
N/A
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 water dish away
take rawhide
take real bone
take toy/object
approach when dog has any object/toy/bone
verbally punish
physically punish
stare at dog
bend over dog
unfamiliar adult enters house or yard
unfamiliar child enters house or yard
familiar adult enters house or yard
familiar child enters house or yard
response toddlers/babies
dog in car at toolbooths/gas stations
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 not on leash
Where are you on a scale of 1 to 5 as follows:
I am here only out of curiosity - problem not serious
I would like to change the problem, but it is not serious
The problem i sserious and I would like to change it, but if it remains unchanged, that's alright.
The problem is very serious and I would like to change it, but if it remains unchanged, I will keep my dog.
The problem is very serious and I would like to change it, if it remains unchanged, I will have my dog euthanized or give him/her up.
Has your dog bitten and broken skin?
Yes
No
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 aggression seen (e.g. all=100%, just one_10%, etc.)?
What parts of the body has the dog bitten and how severe were the injuries?
Is there anything else I should know about your dog?
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