Behaviour Questionnaire
General Information
Please fill out this form carefully and completely. The information you provide will be very important for diagnosing and treating your pet's behaviour.
Owner
Address
Email
example@example.com
Phone number
Vet
Do you give us consent to contact your Veterinary Practice for referral and access to all veterinary records for the above named pet? Please note, that we only work on veterinary referral which includes review of veterinary notes for your pet.
*
Yes
No
Referred by/How did you hear about us?
Information about your pet
Pet's Name
Date of birth
Breed
Dog gender & neuter status
Female Entire
Female Neutered
Male Entire
Male Neutered
If neutered, at what age?
Colour
Weight (approx)
At what age did you obtain the pet?
From where did you obtain this pet? (Rescue, breeder, friend, preloved, Facebook etc?)
If obtained from a breeder, please give the name and location of breeder
For what purpose was the pet obtained? (Companionship, showing, dog sports etc)
Please briefly describe your dog's mum's personality, if you met her:
Please describe your dog's behaviour when you first met him/her and then later as a puppy?
Are you in touch with owners of puppies from the same litter? Are they having similar problems?
Is your pet left alone during the day?
Yes
No
If yes, for how long?
How many adult female humans live in the home?
How many adult male humans live in the home?
How many children live in the home?
Ages of the children
Are there any other pets in the home? (add amount of each in the relevant box)
Rows
Entire
Neutered
Dogs
Cats
Other
Describe your pet's personality
Does your pet follow you about the house when you are at home?
Please provide a floor plan of the ground floor of your home.
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Diet
What type of food do you feed your pet?
Raw
Dry
Canned/pouches
Other
Which brand(s)?
Is your dog given any supplements?
Yes
No
If yes, please list here:
What treats and/or chews does your pet enjoy?
When is the pet fed?
By who?
Does your pet have any allergies?
Medical history
Date of last vet examination (approximate date is fine):
Please list all medical or surgical problems with approximate dates
Please list all medications currently or recently taken by your pet
Training, play and exercise
What toys/types of play does your pet enjoy?
What amount of exercise does your pet have each day?
Has your pet had any formal training?
Private lessons
Training classes
Trained yourself
Other
How old was your dog at the time?
Please grade how successful you felt this training was:
Excellent
Good
Fair
Failed
Please describe the type of training (eg. agility, pet, obedience, tricks etc)
What behaviours or tricks can your pet perform?
Does this pet get along with other animals? If not, please describe their behaviour:
How does your pet react to unfamiliar people?
How do you correct your dog when he/she misbehaves?
Behaviour problems
Please describe your pet's problem behaviour. Add as much detail as you can.
If your pet has more than 1 behaviour problem, please list them in order or priority, where number 1 is the behaviour you would most like to resolve:
What month/year were the problems first noted?
Where and under what circumstances was each problem first noted?
Fully describe the situation in which the behaviour is most likely to occur
How many times a day, week or month does the problem occur?
Rows
Number of times
Times per day
Times per week
Times per month
Has there been a change in the frequency or appearance of the problem? If yes, please describe:
What has been done so far to correct this problem? (eg. How is the pet disciplined, confined, or trained?)
What was the pet's response to the correction?
Have you seen any other behaviourists or trainers about this problem? If so, who?
Were there any significant changes in the pet's environment prior to the appearance of the problem?
Moved or redecorated
Boarded or in kennels
Visitors (human or pet)
Diet changes
Changes in family schedule
New family members/room mates (human or pet)
Illnesses, injury or medication changes
Other
How did these changes affect your pet?
Does your dog carry out any of the following abnormal repetitive or compulsive behaviours?
Tail chasing, circling or spinning
Shadow/light/reflection fixation or chasing
Excessive licking of part(s) of their body
Licking of surfaces, flooring, furniture or bedding
Digging on hard floors or carpet
Snapping at invisible flies
Repetitive pacing
Water obsession/fixation/snapping
Staring at nothing
Eating non-edible objects
Please indicate any other behaviour problems:
House soiling
Destructive chewing
Bites
Digging
Sleep issues
Shyness
Eats stools
Unruly
Grooming
Destructive scratching
Rough playing
Jumps on people
Sexual issues
Barking
Runs away
Pulls on lead
Feeding issues
Aggression
Fights
Other
Is your dog sensitive to noises? If so, please list any noises that he/she reacts to.
Is there a possibility that other pets/humans are contributing to your pet's problem behaviour? If so, please describe further:
Please describe all situations which are likely to elicit aggressive behaviour, such as growling, nipping, biting, attacking (eg. Stroking, approached by adults, approached by children, only when in the car, reaching for, punishing, pushing, taking food or toys away, on the couch, disturbed while sleeping etc....)
Is there any sort of aggression in any of the following circumstances, where aggression includes: growling, snarling (showing teeth), lunging, nipping, biting?
Rows
Adult males
Adult females
Children
Any specific individual
When handling/grooming
If disturbed when resting
If disciplined
When walking on lead
If trying to take food away
When petting or hugging
It taking any other objects away
If your pet has an aggression problem, describe at least the last two or three aggressive incidents in detail.
General Health
Do you notice any of the following in your dog:
Regular or occasional soft poos that leave a residue when picked up
Vomiting more frequently than once a month
Flatulence
Burping
Excessive gulping/swallowing
Very noisy tummy - gurgling noises
Have you noticed any of the following gait abnormalities:
Occasional limping
Bunny hopping (running with back legs together like a rabbit)
Dragging or scuffing feet while moving
Stumbling or losing footing
Slower to move in the mornings or after long periods of inactivity
Hesitation or refusal to jump into the car or onto surfaces
Hopping or skipping over steps
Lifting a leg while going up or downstairs or steps
Are you concerned about any aspect of your dog's health?
And finally...
Under what circumstances would you consider euthanasia?
What do you hope to achieve after our behaviour consultation with your pet?
Please add anything else that you feel is relevant to your pet's problem behaviour:
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