CANINE BEHAVIOR CONSULTATION QUESTIONNAIRE

CANINE BEHAVIOR CONSULTATION QUESTIONNAIRE

Landsberg G, Hunthausen W, Ackerman L 2003 Handbook of Behavior Problems of the Dog and Cat. Saunders, Edinburgh# 2003, Elsevier Science Limited. All rights reserved.
General Information
Name*

First NameLast Name
Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vet Clinic and Veterinarian Name*
Clinic Phone Number
Please enter a valid phone number.
How did you hear about our services?*
Pet Information
Name:*
Age: *
Date of Birth:*
Weight:*
Sex:*

Spayed/Neutered?*
Age Spayed/Neutered:*
Any change after spay/neuter?
Breed:*
Age obtained:
Where did you obtain this pet?
For what purpose was this pet obtained?
Describe previous homes:
Behavior of parents or littermates (if known):
Briefly describe your dog's personality (e.g. quiet, confident, excitable, unruly, etc.)
The Home Environment
Type of food:
How often is your dog fed? When?
How often do you give treats? When?
Any supplements?
List other household pets (species, sex, age):
Describe how your pets get along with each other:
List people in the home (age and sex):
Describe how your pet gets along with each family member including any problems:
Reinforcer Assessment
What is your dog's favorite reward?
List the top 5 foods your dog enjoys:
Other than food, what reward is most enticing to your dog? List 3
Daily Activities and Routine
Type of Exercise:
Who exercises? How often? How long?
What is your dog's favorite game, toy?
Where is your dog's favorite sleeping spot?
Where does your dog sleep at night?
Have you ever used a crate for confinement? If yes, describe crate and location:
Describe your dog's reaction to being crated?
Do you still use a crate? If no, when and why did you stop?
Briefly describe the usual daily schedule for the family:

Housetraining Screen
Where is your dog's primary location for elimination?
How many times a day does your dog urinate?
Defecate?
Is your dog completely housetrained? If yes, proceed to Medical Screen. If no, continue answering questions

YesNo
Do you accompany your dog to elimination spot?
What do you do when you catch your dog eliminating in the correct location?
What do you do when you catch your dog eliminating in the incorrect location?
Does your dog signal to eliminate? Describe:
About how often does your dog housesoil?
When is your dog most likely to housesoil?
Does your dog soil in the home by

UrinatingDefecatingBoth
What are the most likely locations for indoor accidents?
Does your dog housesoil while people are home? Describe:
Does your dog housesoil while you are watching? Describe:
What do you do when you find urine or stool in an improper location?
Does your dog urine mark?
Does your dog ever eliminate in a location he/she has been sleeping?
If confined to a crate, does your dog ever eliminate in the crate?
Does your dog have uncontrollable urination when excited or frightened?
Does your dog leak urine when he/she is

SleepingWalkingApproached by ownerApproached by stranger

Principal Complaint
What is the primary issue? (aggression, destruction, housesoiling, barking, etc.)*
How would you describe the severity of this problem?

MildModerateSevere
Have you considered euthanasia?
When did the problem begin?
What age was your dog when it started?
What do you think caused the problem?
Describe the problem, beginning with the most recent incident:
Describe previous incidents:
Describe the first incident:
How often does the problem occur?
Has there been a recent change in frequency or severity?
Describe any changes in the home or your dog's health when the problem first started:
What has been done to try to correct the problem?
What has been your dog's response?
List any techniques that have been successful:
List any techniques that have made the problem worse:
List any medications you have tried so far and dog's reaction:
List any other dietary supplements or OTC remedies you've tried and your dog's response:

General Information