Behaviour Questionnaire and Intake form

Behavioural Consultation Form

Thank you for taking the time to fill out this form as accurately as you can, before seeing Dr. Michelle for a behavioural consult. Please ensure this form is completed at least 48 hours before your appointment.
Owner Information

Information about you!
Preferred pronouns - let me know how I should refer to you.*

He/himShe/herThey/themOther
Your first name*
Your surname*
Your phone number*
Email
example@example.com
Street address*
Suburb
State
Post Code*
Alternative contact person
Their phone number
In case of emergency
Would you like to receive general information and updates via email?

YesNo
Dog Information

Information about your dog
Name*
Breed*
Weight (kg)
Date of birth*

DayMonthYear
Date
Microchip number
Sex*

Male neuteredMale entireFemale neuteredFemale entire
Current vet clinic email*
Email
Date of last vaccination*

MonthDayYear
Date
Age when purchased
Dog was sourced from:

Registered Breeder (local)Un-Registered Breeder (local)Registered Breeder (interstate)Un-Registered Breeder (interstate)RescueOther
Age and number other people living in the home:
Other pets living in the home:
Have you owned a dog before?

YesNo
Why did you choose this breed of dog?
Why did you choose this particular dog?
Behaviour in detail

More information about your pet's specific situation
Does your dog currently, or have they ever showed any of the following behaviours:

Anxiety (whining, crying, barking, panting)Hyperactivity/overexcitabilityDestructionDisobedienceDepressionDemanding of attentionIssues with toileting (accidents)Problems with appetiteEscapingOther
Is your dog currently taking any supplements or medications?
Eg from a vet, pet store, online etc.
Training Information

Information about past and present trainers
Is your dog currently working with a trainer?*

YesNo
Name of referring trainer
Trainer's name/business name
Trainer email
Trainer's email
Has your dog had any other training?

Puppy school (Eg 4 weeks)Group classesPrivate classesBoard and trainTraining at home (by you)Other
Please list the trainers you have worked with in the past.
Current Trainer
When was the last time your dog participated in training classes

MonthDayYear
Date

How would you rate your dog's ability to learn

	1	2	3	4	5

1 is Poor, 5 is Good

How would you rate your dog's interest in food

	1	2	3	4	5

1 is Poor, 5 is Good

How would you rate your dog's interest in toys/play

	1	2	3	4	5

1 is Poor, 5 is Good

What equipment, techniques or rewards have or have not been helpful in training so far?
Eg halti, high value treats, ball etc.

Please describe how your dog is likely to act in these situations

	Behaviour eg barking, snapping, excitable, tries to avoid, hides, tolerates, enjoys, seeks out)
Unfamiliar visitors at the door/doorbell ringing
Unfamiliar visitor approaching while in the house
Familiar visitors at the door/doorbell ringing
Familiar visitor touching while in the house
Unfamiliar visitor touching while in the house
Unfamiliar visitor approaching while outside the house
Unfamiliar visitor touching while outside the house
Unfamiliar dog approaching while outside the house
Around toys
Around food
Being handled at the vet
Being handled at the groomers
Loud noises (eg fireworks or storms)

Describe your dog's exercise and activities

	Type of exercise	Duration (mins)	Frequency (eg weekly, daily)	Purpose
1
2
3
4
5

Where does your dog spend most of their time when you are at home?

Indoors (free access)OutdoorsIndoors with access outdoorsIndoors (restricted rooms only)Other
Where does your dog spend most of their time when you are NOT at home?

Indoors (free access)OutdoorsIndoors with access outdoorsIndoors (restricted rooms only)Other
Does your dog show any of the following behaviours when left alone?

Barking/whiningPacingPantingTrying to escapeDestructionDiggingToileting inappropriatelyOther
Where does your dog sleep at night?

Indoors (free access)OutdorsCrate or penOther
What activities does your dog do when left alone?
Eg food dispensing toys, sleeping, play etc
What's going on for you right now?

Let's get to the reason you've made the appointment
Please outline the major reason(s) for your visit today*
Eg on leash issues, destruction at home
How long has this been occurring?
Please describe the first time it occurred
Please describe any major instances this issue has occurred
Have you tried any methods to solve this problem? What was or wasn't helpful?
Safety

Information to keep us all safe
Has your dog showed any of the following behaviours towards people?

LungingGrowling, snarlingSnapping or biting
If yes, in what situations do you perceive this is likely to occur?
Has your dog ever made contact with their teeth on a person?*

YesNo
Has your dog ever injured another person or animal?*

YesNo
Is your dog currently involved in any legal proceedings?*

YesNo
Reflection

How does this all make you feel?
How would you feel if you were unable to solve your dog's behavioural issues?
Eg frustrated, would consider rehoming etc.
How would the other members of your household feel if you were unable to solve your dog's behavioural issues.
What are you goals and hopes for your dog in the future?
Eg be able to walk them on leash, have them spend time alone etc.
Is there anything else you'd like to add?
Medication planning

Your local pharmacy's details
Pharmacy name
Pharmacy address

Street Address

Street Address Line 2

SuburbState

Post Code
Pharmacy email
example@example.com
Safety declaration

Just before we meet up in person.
I will keep my dog in the car, and call on my arrival at the venue.*

YesNo
I am able to keep my restrained and at a distance if required, and will not allow my dog to approach any other person unless instructed.*

YesNo
My dog's equipment (eg leash, collar) is well fitting, secure, and in good condition, and my dog will not be able to escape my control.*

YesNo
Thank you for taking the time to fill out this form, I know it's a long one. The more detail you're able to provide, the more time we can spend in consult focusing on you and your dog's needs.
Should be Empty:

Behavioural Consultation Form

Owner Information

Dog Information

Behaviour in detail

Training Information

What's going on for you right now?

Safety

Reflection

Medication planning

Safety declaration