Canine Behaviour Consultation Questionnaire

Canine Behaviour Consultation Questionnaire
Client Information
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (Primary) *
Please enter a valid phone number.
Phone Number (Seconday)
Please enter a valid phone number.
How did you hear about our service?
Preferred Form Of Communication *

Phone Text E-Mail
Preferred Time Of Appointment *

Morning (Between 9am-11am) Afternoon (Between 1pm-4pm) Evening (Between 5pm-7pm)
Regular DVM
Name Practice
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please enter a valid phone number.

Pet Information
Dog's Name
Date of Birth

Month Day Year
Date
Pets Weight
Pounds Kilograms
Breed
Colour
Sex

Male Female
Neutered/Spayed Intact
Any behavioural changes after spay/neuter?

Yes No I don't know
Please describe
How old was pet when they joined your family?
Weeks Months Years
Where did you obtain your pet?
Describe previous home(s)
If known
Describe behaviour of parents/littermates
If known
For what purpose did you obtain this pet?

Companionship Protection Working Emotional Support Other
Briefly describe your dogs personality

The home environment
What type of food does your dog eat?
How many times per day is your dog fed?
What time(s) of day is your dog fed?
How often do you feed treats?
What type of treats do you feed?
Do you have other pets in the home?

Yes No
List all other pets in the home (including species, breed, age, and sex)
Describe how your pets get along with each other
List all family members/roommates living in the home (please include age of any children)
Briefly describe how your dog gets along with each member of the household, including any special relationships or problems.

Daily Activities and Routines
Does your dog get physical exercise daily?

Yes No Sometimes
What type of physical exercise does your dog get?
Who exercises/plays with your dog?
How often/ how long is your pet exercised?
Does your dog get mental exercise (training, puzzle games, thinking games etc.) daily?

Yes No Sometimes
What type of mental exercise does your dog get?
Who provides the mental exercise for your dog?
How often/how long is your pet mentally exercised?
What is your dogs favorite game?
What are your dogs favorite toys?
Where is your dogs favored sleeping spot during the day?
Where does your dog sleep at night?
Have you ever used a crate for confinement?

Yes No
Describe crate and location
Do you still use a crate?

Yes No Sometimes
Why did you stop using a crate?
Describe what the usual daily schedule is for the family from the time you get up to the time you go to bed.

Training
Obedience Training

Group Class Private Instructor I trained my pet at home No obedience training
Type of training

Reward Based Assertive/Domineering Aversive/Mostly Corrections Balanced Other
Briefly describe training techniques:
Which training was MOST effective?

Reward Based Assertive/Domineering Aversive/Mostly Corrections Balanced Other
Which training was LEAST effective

Reward Based Assertive/Domineering Aversive/Mostly Corrections Balanced Other
Describe your dogs learning ability

Training collars- Please rate your dogs response to the following (select all that apply)

	Have not used	Negative or Aggressive Response	Negative or Fearful Response	Neutral Response (Behaviour neither improved or worsened)	Positive Response (Behaviour improved)	Additional Comments
None- Trained off leash
Flat Collar
Pinch Collar
Prong Collar
Electronic Collar(Stim)
Electronic Collar (Shock)
Electronic Collar (Spray)
Body Harness (Front Clip)
Body Harness (Back Clip)
Head Collar
Choke Collar
Martingale Collar

List family members with the MOST control
List family members with the LEAST control

Please indicate how your dog responds to the following commands. Excellent= in all environments Good= except for major distractions Fair= does not listen if distractions Poor= occasionally listens when it seems convenient Never= listens on the rare occasion or not at all

	Excellent	Good	Fair	Poor	Never	Not Applicable	Comments
Sit (Immediate)
Sit-Focus (1 minute)
Sit-Focus (5 minute)
Down (Immediate)
Down-Settle (1 minute)
Down-Settle (5 minute)
Come- Indoors
Come- In yard
Come- In park/ public
Leave It
Walk on loose leash
Turn/Lets go/ Back up
Give/Drop- Toy
Give/Drop- Stolen Object
Go to bed
Go to kennel
Go to mat
Watch/Focus/Look at me

Does your dog know any additional tricks/ commands?

Yes No
List/Explain
Can you get your dog to settle on command?

Yes No Maybe
Please explain:

Have you ever used any of the following for punishment or training?

	Yes	No	Dogs reaction	Additional comments
Physical Punishment (ie; slap, hit, push)
Noise Punishment (ie; shaker can, air horn, siren)
Ultrasonic
Water sprayer
Verbal reprimands
Physical Handling- Muzzle Grasp
Physical Handling- Pinning
Time out
Booby traps or repellants

Did any punishment make the behaviour worse?

Yes No
Please explain:
Has any punishment ever led to aggressive or threatening behaviour?

Yes No
Please explain:
Does your dog respond differently to punishment form different family members?

Yes No
Please explain:

Handling

Please indicate how your dog responds to the following

	Not tried	Enjoys	Accepts Willingly	Accepts Reluctantly	Resists	Threatens/Aggressive
Nail Trimming
Brushing
Rubbing Belly
Grabbing Collar- Family Member
Grabbing Collar- Unfamiliar Person
Rolling Over
Giving Pills
Hugging/Kissing
Ear Cleaning
Bathing
Patting Head
Being Lifted
Teeth Brushing
Giving Liquid Medication

Housetraining
Is your dog completely housetrained?

Yes No
Where is your dog's primary location for elimination?
On average, how many times a day does your dog urinate?
On average, how many times a day does your dog defecate?
Does your dog ever eliminate outdoors?

Yes No
Where is your dogs favored location to eliminate outdoors?
Where is your preferred location for your dog to eliminate?
What is your reaction when your dog eliminates in the correct or preferred location?
What is your reaction when your dog eliminates in an incorrect or non-preferred location?
Does your dog signal to eliminate?

Yes No Sometimes
Please describe
Does your dog soil in the home by

Urinating Defecating Both
How often does your dog housesoil?
When is your dog most likely to housesoil?
What are the most likely locations for indoor elimination? Please be as specific as possible
Does your dog housesoil when family members are home?

Yes No
Please explain
Does your dog housesoil when you are watching?

Yes No Sometimes
Please explain
What do you do when you find urine or stool in the improper location?
Does your dog urine mark?

Yes No
Please list locations

Does your dog ever

	Yes	No
Eliminate in a location where he/she has been sleeping?
Leak or dribble urine while sleeping?
Leak or dribble urine while awake?
Leak or dribble urine while walking?
Leak or dribble urine when approached by family/friends?
Leak or dribble urine when approached by stranger?
Uncontrollably urinate when excited?
Uncontrollable urinate when frightened?

Do you ever confine your dog to a crate?

Yes No
Does your dog ever eliminate in it's crate?

Yes No Sometimes
Please explain

Departure Behaviour Screening
Does your dog display any undesirable behaviours when left alone?

Yes No
When you go out is your dog

Confined to a crate Confined to a room Not confined
Please describe crate size, makeup and location
Please describe room size and location and how your dog is confined here
How long is your dog left alone on the average day?
At what time of day is your dog left alone?
Please describe how your dog reacts as you prepare to leave. Be as detailed as possible.
Please describe your dogs behaviour when left home alone, including the undesirable behaviours, how long after departure they start, duration and severity of the behaviours as well as any other information you
Does the behaviour differ depending on length of time or time of day left alone?

Yes No
Please describe
Does your dogs behaviour change depending on who is the last to leave?

Yes No
Please explain
Has your dog ever been left at a

Kennel Veterinary Office Friend/Relatives Home Other
Please describe your dogs reaction to being left
Is your dog ever left alone outside?

Yes No
Does your dog exhibit any undesirable behaviours when left alone outside?

Yes No
How often is your dog left along outside?
For how long is your dog left along outside?
Please describe the location where your dog is left alone outside
If your dog ever left alone in the car?

Yes No
Does your dog exhibit any undesirable behaviours when left alone in the car?

Yes No
Please describe including how long after being left in the car undesirable behaviours occur, how long they last for and what the undesirable behaviours are
Please describe in as much detail as you can your dogs behaviour on homecomings
Does your dogs homecoming behaviour change depending on who is coming home?

Yes No
Please describe

Reactivity Screening

Please indicate how your dog reacts to each of the following

	Calm	Excited	Friendly	Ambivalent	Fearful	Aggressive	Unknown	Additional Comments
Familiar dogs on property- Meeting on leash
Familiar dogs on property- Meeting off leash
Familiar dogs off property- Meeting on leash
Familiar dogs off property- Meeting off leash
Unfamiliar dogs on property- Meeting on leash
Unfamiliar dogs on property- Meeting off leash
Unfamiliar dogs off property- Meeting on leash
Unfamiliar dogs off property- Meeting off leash
Familiar people outside on property
Unfamiliar people outside on property
Familiar people off property
Unfamiliar people off property
Familiar people arriving indoors
Unfamiliar people arriving indoors
Car rides
Thuunderstorms
Fire works
Other loud noises
Squirrels/Prey
Cats
Children
Vehicles
Bikes
Skateboards

Aggression Screening
Does your dog display aggression?

Yes No
What is the primary type of aggression? (Select all that apply)

Threat/ No bite Snap/ No contact Bite/Release Bite/No release Bite/No release, shake Multiple bites
What do you believe is the potential for injury?

None Minimal Moderate Severe
Is the aggression serious enough that you will be unable to keep your dog if it is not improved?

Yes No I'm not sure
Have you considered euthanasia of your dog due to aggression problems?

Yes No I'm not sure
Do you believe that you are able to predict and avoid or prevent all situations in which aggression might arise?

Yes No I'm not sure Type option 4
Please explain
Describe your dogs attitude during aggression (ie. bold, protective, outgoing, fearful)
Describe your dogs expression during aggression (ie. cowering, hackles raised, ears flat)
Does your dog exhibit aggression towards a familiar person?

Yes No

What is your dogs reaction to the following situations (FAMILIAR PERSON) (select all that apply)

	Unknown	No Reaction	Growl/Threat	Snap/No contac	Bite	Multiple Bites	Who is the target?	Additional Comments
Stares at dog
Reaches for/bends over
Petting dog
Hugging/Kissing dog
Lifting dog
Pins/Rolls over
Putting on or taking off leash/collar
Gives verbal cue in normal tone
Uses verbal discipline
Grabs Collar
Physical hit or leash correction
In response to movement
In response to noises/yelling
Interrupts threat or bite directed at person/dog
Approach family member
Hug/Touch family member

Does your dog show any aggression towards an unfamiliar person?

Yes No

What is your dogs reaction to the following situations (UNFAMILIAR PERSON) (select all that apply)

	Unknown	No Reaction	Growl/Threat	Snap/No contac	Bite	Multiple Bites	Who is the target?	Additional Comments
Stares at dog
Reaches for/bends over
Petting dog
Hugging/Kissing dog
Lifting dog
Pins/Rolls over
Putting on or taking off leash/collar
Gives verbal cue in normal tone
Uses verbal discipline
Grabs Collar
Physical hit or leash correction
In response to movement
In response to noises/yelling
Interrupts threat or bite directed at person/dog
Approach family member
Hug/Touch family member
Comes into home
Comes onto property
Leaves home
Leaves property

Does your dog show aggression during handling/grooming?

Yes No

What is your dogs reaction to the following situations (FAMILIAR PERSON) (select all that apply)

	Unknown	No Reaction	Growl/Threat	Snap/No contac	Bite	Multiple Bites	Who is the target?	Additional Comments
Bathes
Grooms
Towels
Treats ears
Treats eyes
Trims nails
Approaches dog when with family member
Approaches dog when on it's mat/bed
Approaches dog when resting on furniture

What is your dogs reaction to the following situations (UNFAMILIAR PERSON) (select all that apply)

	Unknown	No Reaction	Growl/Threat	Snap/No contac	Bite	Multiple Bites	Who is the target?	Additional Comments
Bathes
Grooms
Towels
Treats ears
Treats eyes
Trims nails
Approaches dog when with family member
Approaches dog when on it's mat/bed
Approaches dog when resting on furniture
Behaviour during veterinary exam

Does your dog show aggression towards other animals?

Yes No

What is your dogs reaction to the following (select all that apply)

	Unknown	No Reaction	Growl/Threat	Snap/No contac	Bite	Multiple Bites	Who is the target?	Additional Comments
Familiar animals on property
Familiar dog on property
Other pets in home
Familiar dogs off property
Unfamiliar animals on property
Unfamiliar dogs on property
Unfamiliar dogs off property

Does your dog show any aggression around food, treats or toys?

Yes No

What is your dogs reaction to the following (select all that apply)

	Unknown	No Reaction	Growl/Threat	Snap/No contac	Bite	Multiple Bites	Who is the target?	Additional Comments
Familiar person approaches dog while eating food
Familiar person approaches dog while eating treats
Familiar person approaches dog while playing with toys
Familiar person takes away stolen object
Unfamiliar person approaches dog while eating food
Unfamiliar person approaches dog while eating treats
Unfamiliar person approaches dog while playing with toys
Unfamiliar person takes away stolen object
Familiar animal approaches dog while eating food
Familiar animal approaches dog while eating treats
Familiar animal approaches dog while playing with toys
Unfamiliar animal approaches dog while eating food
Unfamiliar animal approaches dog while eating treats
Unfamiliar animal approaches dog while playing with toys

Miscellaneous

Please select other behaviours that your pet displays

	Does not occur	Occurs- No Concern	Occurs Low Concern	Occurs High Concern	Additional Comments
Vocalizations- bark, whine, howl
Jumps up on familiar people
Jumps up on unfamiliar people
Won't come when called
Nips/Grabs with mouth
Selective listening
Pushy/Demanding
In off limits rooms
On off limits furniture
Clingy
Stool eating
Chases
Hunting/Predation
Garbage Raiding
Food stealing
Night Waking
Digging
Licks objects
Eats non-food items
Tail chasing/spinning
Excessive grooming
Staring
Stargazing
Fly chasing
Light chasing
Masturbation
Mounting
Roaming/Running Away

Reinforcement Assessment
What is your dog's favorite reward?
If you could give your dog ANY food as a reward, what would be the top five favorites.
Other than food, what rewards (i.e. toys, affection, movement) would be most enticing to your dog? List the top five.

Medical Screening
Has your dog been to a veterinarian for a physical examination in the past 12 months?

Yes No
Has your dog had labwork (bloodwork, urinalysis, etc) in the past 12 months?

Yes No I don't know
Appetite (Select all that apply)

Normal Voracious Decreased Picky Increased Eats Fast Eats slowly I'm having trouble getting my dog to eat
Does your dog have arthritis or other painful conditions?

Yes No I don't know
Please describe
Have you noticed an deficits in your pets senses?

Yes No I don't know
Please describe
Does your pet drink or urinate excessively?

Yes No I don't know
Please describe
Stool Quality

Normal Constipation Less Frequent More Frequent Soft/Diarrhea
Please describe
Urine

Normal Infrequent More Frequent Less Volume More Volume
Please describe
Does your dog have any other medical problems?

Yes No I don't know
Please describe
Is your pet presently on any medication or supplements?

Yes No
Please list, including name, dosage, duration:
Should be Empty:

Canine Behaviour Consultation Questionnaire

Client Information

Regular DVM

Pet Information

The home environment

Daily Activities and Routines

Training

Handling

Housetraining

Departure Behaviour Screening

Reactivity Screening

Aggression Screening

Miscellaneous

Reinforcement Assessment

Medical Screening