• Canine Behaviour Consultation Questionnaire

• Client Information

• Name*
  First NameLast Name
• Email*
  example@example.com
• Address*
  Street Address

  Street Address Line 2

  CityState / 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*
  PhoneTextE-Mail
• Preferred Time Of Appointment*
  Morning (Between 9am-11am)Afternoon (Between 1pm-4pm)Evening (Between 5pm-7pm)

• Regular DVM

• NamePractice
• Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• Please enter a valid phone number.
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• Pet Information

• Dog's Name
• Date of Birth
   -Month -DayYear

  Date
• Pets Weight
• PoundsKilograms
• Breed
• Colour
• Sex
  MaleFemale
• Neutered/SpayedIntact
• Any behavioural changes after spay/neuter?
  YesNoI don't know
• Please describe
• How old was pet when they joined your family?
• WeeksMonthsYears
• 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?
  CompanionshipProtectionWorkingEmotional SupportOther
• Briefly describe your dogs personality
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• 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?
  YesNo
• 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.
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• Daily Activities and Routines

• Does your dog get physical exercise daily?
  YesNoSometimes
• 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?
  YesNoSometimes
• 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?
  YesNo
• Describe crate and location
• Do you still use a crate?
  YesNoSometimes
• 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.
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• Training

• Obedience Training
  Group ClassPrivate InstructorI trained my pet at homeNo obedience training
• Type of training
  Reward BasedAssertive/DomineeringAversive/Mostly CorrectionsBalancedOther
• Briefly describe training techniques:
• Which training was MOST effective?
  Reward BasedAssertive/DomineeringAversive/Mostly CorrectionsBalancedOther
• Which training was LEAST effective
  Reward BasedAssertive/DomineeringAversive/Mostly CorrectionsBalancedOther
• 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?
  YesNo
• List/Explain
• Can you get your dog to settle on command?
  YesNoMaybe
• 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?
  YesNo
• Please explain:
• Has any punishment ever led to aggressive or threatening behaviour?
  YesNo
• Please explain:
• Does your dog respond differently to punishment form different family members?
  YesNo
• Please explain:
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• 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

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• Housetraining

• Is your dog completely housetrained?
  YesNo
• 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?
  YesNo
• 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?
  YesNoSometimes
• Please describe
• Does your dog soil in the home by
  UrinatingDefecatingBoth
• 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?
  YesNo
• Please explain
• Does your dog housesoil when you are watching?
  YesNoSometimes
• Please explain
• What do you do when you find urine or stool in the improper location?
• Does your dog urine mark?
  YesNo
• 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?
  YesNo
• Does your dog ever eliminate in it's crate?
  YesNoSometimes
• Please explain
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• Departure Behaviour Screening

• Does your dog display any undesirable behaviours when left alone?
  YesNo
• When you go out is your dog
  Confined to a crateConfined to a roomNot 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?
  YesNo
• Please describe
• Does your dogs behaviour change depending on who is the last to leave?
  YesNo
• Please explain
• Has your dog ever been left at a
  KennelVeterinary OfficeFriend/Relatives HomeOther
• Please describe your dogs reaction to being left
• Is your dog ever left alone outside?
  YesNo
• Does your dog exhibit any undesirable behaviours when left alone outside?
  YesNo
• 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?
  YesNo
• Does your dog exhibit any undesirable behaviours when left alone in the car?
  YesNo
• 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?
  YesNo
• Please describe
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• 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

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• Aggression Screening

• Does your dog display aggression?
  YesNo
• What is the primary type of aggression? (Select all that apply)
  Threat/ No biteSnap/ No contactBite/ReleaseBite/No releaseBite/No release, shakeMultiple bites
• What do you believe is the potential for injury?
  NoneMinimalModerateSevere
• Is the aggression serious enough that you will be unable to keep your dog if it is not improved?
  YesNoI'm not sure
• Have you considered euthanasia of your dog due to aggression problems?
  YesNoI'm not sure
• Do you believe that you are able to predict and avoid or prevent all situations in which aggression might arise?
  YesNoI'm not sureType 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?
  YesNo
• 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?
  YesNo
• 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?
  YesNo
• 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?
  YesNo
• 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?
  YesNo
• 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

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• 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

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• 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.
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• Medical Screening

• Has your dog been to a veterinarian for a physical examination in the past 12 months?
  YesNo
• Has your dog had labwork (bloodwork, urinalysis, etc) in the past 12 months?
  YesNoI don't know
• Appetite (Select all that apply)
  NormalVoraciousDecreasedPickyIncreasedEats FastEats slowlyI'm having trouble getting my dog to eat
• Does your dog have arthritis or other painful conditions?
  YesNoI don't know
• Please describe
• Have you noticed an deficits in your pets senses?
  YesNoI don't know
• Please describe
• Does your pet drink or urinate excessively?
  YesNoI don't know
• Please describe
• Stool Quality
  NormalConstipationLess FrequentMore FrequentSoft/Diarrhea
• Please describe
• Urine
  NormalInfrequentMore FrequentLess VolumeMore Volume
• Please describe
• Does your dog have any other medical problems?
  YesNoI don't know
• Please describe
• Is your pet presently on any medication or supplements?
  YesNo
• Please list, including name, dosage, duration:
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