BASIC HISTORY QUESTIONNAIRE-DOGS

BASIC HISTORY QUESTIONNAIRE-DOGS

The questionnaire that follows focuses on all aspects of your dog's behavior and any health issues that could contribute to behavioral concerns.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Pet's Name
Breed
Female, unspayedFemale, spayedMale, intactMale, neutered
Puppy (under 12 months of age)Juevanile (one to two years of age)Adult (3 to 8 years of age)Senior (9 to 12 years of age)Geriatric (13 plus years of age)
Pet's age (your best guess)
(Please specify years or months)
Pet Weight (in pounds)
Pet Body Condition Score
Use the table below to choose number 1 through 5 that best approximates your pet's shape

Rows	Yes	No
Have you owned dogs before?
Have you owned this breed before?

How old was your pet when you acquired him/her?
Please include weeks, months or years
NoUnsure1 other owner2 other owners3 others4 or more previous owners
Where did you acquire your dog?
Why did you get this dog? Please include why you picked this specific breed and/or this particular dog.
Please list all people, including yourself, currently living in the household. Use self for relationship of person completing form.*
Please list all pets (including non-dog pets), currently living in the household. *
When was your dog last vaccinated, if new to us?
When did your dog last see a veterinarian, if new to us?
Please list any medical problems noted by your veterinarian, if new to us.

Preventatives:

Rows	Yes	No
Is your dog on heartworm preventative every month?
Is your dog on flea preventatives?

Please list all medications your dog takes. Select "Add Additional Lines" to list multiple medications. Use the "Meds not listed" for any medications not given as an option.*
Has your dog been prescribed any other medications in the past specifically for behavior concerns?*
My dog eats the following brand of food: brand of food .
He/She eats   enter number of cups cups at each feeding.
Feedings occur at the following times:   Time   Time   Time
Please describe any treats, snacks, bones, etc. you pet receives, the amount of each and frequency:   snack types,   snack amount ,  snack frequency.
Does your pet get table food?   Yes   No
General appetite :   Excellent   Good with occasional skipped meals   Finicky    Generally poor appetite
Does your pet have periodic gastrointestinal distress?    No distress   sometimes poor appetite or vomiting   Soft stools or diarrhea   Straining, occasionally no stools   Unsure
Does your pet:   Eat grass, dirt or other objects frequently   Lick the floors, bed, or furniture frequently
How is your dog exercised?
How is your dog kept when you leave home?
Where does your dog sleep? (select all that apply)
ApartmentCondo/TownhouseHouse with small yardHouse with large yardFarmOther
NoDeath of family memberDeath of another family petDivorceMarriageChild bornChild moved from homeFamily schedule changePet addedOther family member addedMovedOther
NoneTrained yourselfPrivate trainerSent to a private trainerPuppy kindergartenGroup basic lessonsGroup advanced lessonsAgilityFlyballSpecialty training (hunting/herding, etc)Other
How many walks per day on average does your dog get? number of walks
How long are most walks?   length of walk
How many play sessions does your pet get each day?  play sessions
How many training sessions per day?   training sessions
How many hours per 24 hour day is your dog usually inside?
How many hours per 24 hour day is your dog outside?
Age when dog started lessons/training
Who took the dog to training?
PerfectOKNeeds workBadly
How well does this dog do with the following cues/requests?
Please describe, in detail, how you prepare to leave the house when the dog will be left alone. Do you ignore the dog, do you seek him/her out to say goodbye, do you make a fuss, give a treat, et cetera?
What does your dog do as you prepare to leave?
Please list your dog's most pressing 1 to 3 behavior problem(s) and let us know how serious of a problem you consider the behavior to be. Then estimate the duration and frequency of occurrence of the undesirable behavior and the percentage of time spent in each behavior. Use the "Add" button to list additional major problem behaviors.*
Why have you kept the dog despite the problems?
Questions regarding the behaviors
Anything else you would like us to know about the behaviors you find most disruptive?
Select the amount of time your pet spends in each type of behavior during separation from the owner:
Within 5 minutesMore than 5 minutes but less than 30 minutesMore than 30 minutes, but less than 1 hourMore than 1 hour, but less than 3 hoursOnly after several hoursUnsure
20 minutes or less with no recurrence20 minutes or less but recur after some period of quietContinuousUnsureOther
Separation Anxiety Continued: The second set of questions deals with "virtual absence"-the owner is home, but not accessible because the door is closed or the dog is barricaded in another room.
Select the amount of time your pet spends in each type of behavior during a "virtual absence" from the owner:
Within 5 minutesMore than 5 minutes but less than 30 minutesMore than 30 minutes, but less than 1 hourMore than 1 hour, but less than 3 hoursOnly after several hoursUnsure
20 minutes or less with no recurrence20 minutes or less but recur after some period of quietContinuousUnsureOther
Please add any additional comments you feel are necessary to fully describe your pet's situation with regardsto separation anxiety.
Please indicate both the reaction and timing of your dog during thunderstorms.
Please indicate both the reaction and timing of your dog during fireworks or gunshots.
Is there anything else you notice about your dog with regards to noise or sounds?
Concerning bites to people or other animals...*
Select your dog's reaction to the following. Do NOT test these scenarios in order to gain an answer. Mark not applicable/Unsure if your dog has not been in these situations. We are only interested in situations experienced in the past.
Select your dog's reaction to the following. Do NOT test these scenarios in order to gain an answer. Mark not applicable/Unsure if your dog has not been in these situations. We are only interested in situations experienced in the past.
Select your dog's reaction to the following. Do NOT test these scenarios in order to gain an answer. Mark not applicable/Unsure if your dog has not been in these situations. We are only interested in situations experienced in the past.
Select your dog's reaction to the following. Do NOT test these scenarios in order to gain an answer. Mark not applicable/Unsure if your dog has not been in these situations. We are only interested in situations experienced in the past.
Select your dog's reaction to the following. Do NOT test these scenarios in order to gain an answer. Mark not applicable/Unsure if your dog has not been in these situations. We are only interested in situations experienced in the past.
Select your dog's reaction to the following. Do NOT test these scenarios in order to gain an answer. Mark not applicable/Unsure if your dog has not been in these situations. We are only interested in situations experienced in the past.
Select your dog's reaction to the following. Do NOT test these scenarios in order to gain an answer. Mark not applicable/Unsure if your dog has not been in these situations. We are only interested in situations experienced in the past.
Please note if the reaction is consistent in style, only directed toward one person or animal, or only present in one circumstance.
You may have been given many suggestions of ways to respond to or methods to train your dog. This is not a judgment on what is or is not appropriate but simply to determine what has been tried in the past. Please select all that have been attempted.*
Chewing at selfLicking selfBiting selfSucking on selfPlucking hair from selfBarbering or trimming hair from selfPerforming any of these behaviors on another individualOtherNone of these
Consuming rocksConsuming dirt or soilLicking or gulping airEating or sucking fabric, plastic, rugs, furnitureConsuming other objectsEating from only one side of a bowl or plateOtherNone of these
Spinning or circlingTail chasingFreezingOtherNone of these
Rhythmic barkingHowlingGrowlingOtherNone of these
Staring at things that aren't thereTracking things that aren't thereAttacking things that aren't thereOtherNone of these
YesNo
YesNo
YesNo
If yes, please describe the household change in detail.
Continued questions regarding repetitive types of behaviors described above.*
Locomotory/Ambulatory Assessment (This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 1 O years for smaller ones).
Visual Acuity Assessment (This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 1 O years for smaller ones).
Auditory Acuity Assessment (This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 1 O years for smaller ones).
Appetite Assessment (This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 1 O years for smaller ones).
Elimination Assessment (This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 1 O years for smaller ones).
Interaction Assessment - with toys, people and other pets (This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 1 O years for smaller ones).
Sleep Cycle Assessment - with toys, people and other pets (This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 1 O years for smaller ones).
Is there anything else you want us to know?
Should be Empty:

BASIC HISTORY QUESTIONNAIRE-DOGS

Separation Anxiety Continued: The second set of questions deals with "virtual absence"-the owner is home, but not accessible because the door is closed or the dog is barricaded in another room.