Behavior Consult Questionnaire AWayne

Behavior Consult Questionnaire
Appointment date and time
If the forms are not received 48 hours prior to the appointment time, you may be rescheduled.
Owner Name

First NameLast Name
Email
example@example.com
Home Phone
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Please fill out this form carefully and completely. The information which you provide will be very important in diagnosing and treating your pet's behavior problems.
General Information
Pet's Name
Species

DogCat
Age in years/months
Pet Sex

MaleNeutered MaleFemaleSpayed Female
If spayed or neutered, at what age was the process done?
Breed / Color
Weight
At what age did you obtain your pet?
Where did you obtain the pet?

BreederRescueFriendPet ShopOther
For what purpose was the pet obtained?

CompanionshipProtectionBreedingShowOther
What percent of time is spent indoors? Outdoors?
Is the pet left alone during the day?

YesNo
If yes, how long?
In what areas of the house or yard is your pet kept in when family is at home?
In what areas of the house or yard is your pet kept in when family is away?
In what areas of the house or yard is your pet kept in when family is asleep?
In what areas of the house or yard is your pet kept in when guests are visiting?
Does your pet have access to the yard through a dog / cat door?

YesNo
Describe your pet's personality:
Describe your pet's behavior just prior to your departure:
Describe your pet's behavior after your return:
What is your pet's diet? Please include all food and treats regularly given:
What percent is dry food? Canned food? Wet food? And what brands?
Does your pet receive table scraps?

YesNo
If your pet is on any supplements, please list them here:
When is the pet fed, and how many times a day? By whom?
Please list the date of your pet's last physical exam:

MonthDayYear
Date
Please list all major surgical or medical problems, and their approximate start and end date if applicable:
Please list all medications (including dosage in mg, schedule, and duration) that have been prescribed for a behavioral problem, and their results:
Please list all medications (including dosage in mg and schedule) currently being taken by this pet:
Please list the number of other pets in the home, including species and sex status (male, female, neutered or spayed)
What toys / types of play does this pet enjoy?
What amount of exercise or opportunity to exercise is given to the pet?
Does he / she run free int he neighborhood

YesNo
How often?
Has this pet had any formal obedience training?

YesNo
If yes, how many classes? Was this private or group instruction? What did you train?
What kind of collar do you use for training?

FlatChoke ChainPinch / ProngHead Halter
Grade the success of training

FailedFairGoodExcellent
Describe the type of training used:
Does this pet get along with other animals? If not, please explain:
How does this pet react to unfamiliar people:
What persons are in this pet's environment? Their schedules? Children's Ages?:
Behavior Problem Information
Please describe your pet's behavior problem(s):
What month / year were the problem(s) first noted:
Where and under what circumstances was each problem first noted?
Describe the situation(s) in which the problem is most likely to occur?
Please indicate the frequency the problem occurs in each situation.
When the pet is left alone

AlwaysUsuallyRarelyNever
In the presence of family members

AlwaysUsuallyRarelyNever
During the night when the family sleeps

AlwaysUsuallyRarelyNever
For any of the above frequencies selected above never, please list the amount of times per day/week/month/year:
Has there been a change in he frequency or appearance of the problem?

YesNo
Please describe:
What has been done so far to correct this problem? (e.g. discipline, confinement, obedience training)?
What was the pet's response to the correction?
Were there any significant changes in this pet's environment prior to the appearance of the problem?

Moved or redecoratedChange in family's scheduleBoardedVisitors (human or pet)Diet changeNew family member / roommate / petOther
How did these changes affect your pet?
Please indicate other behavioral issues?

House oilsShyPlayPulls hard on leashDestructive chewingEats stoolJumps on peopleFeedingPacingUnrulySexualAggressiveBitesGroomingBarkingFightsDiggingLearningRuns awaySleepSwallowing non-food itemsDestructive scratching
Please describe all situations which are likely to elicit aggressive behavior, such as growling, nipping, biting, attacking(e.g., petting, approached by adults, approached by children, only in the car, reaching for, punishing, pushing, taking food or toys away, disturbed while sleeping):
If you pet has an aggression problem, describe at least the last 2-3 aggressive incidents in detail (You may use the back of the page). Please discuss in detail any other information which you feel is relevant to your pet’s problem:
Housesoiling Data Sheet
Pet's Name:
Date

MonthDayYear
Date
What percentage of the elimination accidents are Urine or Stool?
Does this pet urinate when pet?

YesNo
Does this pet urinate when excited?

YesNo
Does this pet urinate when scolded or punished?

YesNo
Does your pet show a preference for urinating inappropriately on:

Upright surfaces? (walls, sides of furniture, drapes)Horizontal surfaces? (floors, top of counter or furniture)Secluded areas? (closets, under furniture)No preference
Do strays from other households frequently visit or call outside windows, doors, or in the yard?

YesNo
Is there a surface preference for inappropriate elimination?

RugsClothingPaperSoilHard-surfacesOther
If your pet was housetrained, what age were they housetrained?
If your pet was housetrained, what was the method and outcome of the traiing?
Has your pet ever had cystitis (urinary bladder infection)

YesNo
Does any straining or pain accompany urination?

YesNo
Does any straining or pain accompany defecation?

YesNo
Have you noticed blood in the urine?

YesNo
Have you noticed blood in the stool?

YesNo
is there an increased frequency of urination?

YesNo
is there an increased frequency of defecation?

YesNo
Has there been an increase in water consumption?

YesNo
Has there been an increase in the amount of urine voided?

YesNo
Does the stool have an abnormal appearance?

YesNo
What was the date of the last urinalysis?

MonthDayYear
Date
What were the results?
Litterbox information (cats):
Has this pet ever eliminated consistently in the litterbox?

YesNo
When indoors, what percent of the time does the pet defecate in the litterbox as opposed to outside it?
When indoors, what percent of the time does the pet urinate in the litterbox as opposed to outside it?
How many litterboxes are available?
How many of those litterboxes are covered?
How often are those litterboxes cleaned?
What is the type of litter used in the litterboxes?
What brand of litter is being used? How long has that brand been used?
Where are the litterboxes kept?
Please prepare a diagrom of your house for the upcoming visit - indicate areas of inappropriate urination, defecation, urine spraying, litterbox positions (for cats), and feeding areas. This information helps us decipher your pet's problem.
Should be Empty:

Behavior Consult Questionnaire

General Information

Behavior Problem Information

Housesoiling Data Sheet