Canine Behavior Consult Request & Questionnaire (Updated Aug 2022)

Your Pet's Information
Has your pet ever visited Mount Laurel Animal Hospital?*

YesNo, they have never been seen at your facility.
Pet’s Name*
Pet's Age (or date of birth, if known)*
Please provide the best approximation of your pet's age.
Is this Estimated or Known

EstimatedKnown
Sex & Alteration Status*
Breed*
Coat/fur/hair color*
Ex: brown & white

Primary Vet Information

Please have your pet's veterinary records emailed to Appointments@mlahvet.com or fax Attn: Behavioral Medicine to (856) 231-8393.
Veterinary Hospital/Clinic Name*
Veterinarian's Name:
Veterinarian's Phone
Veterinarian's E-Mail
example@example.com
Veterinarian's Address

Street Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Referral Information
Who referred you to MLAH's Behavioral Service Department? *

HOME ENVIRONMENT

Please list all of the people living in your household, including yourself:*

	Name	Age	Gender Identity	Pronouns	Occupation	Avg. Hours NOT Home Per Day	Quality of Relationship with Dog
Yourself
Person 2 (Notate relationship to yourself)
Person 3 (Notate relationship to yourself)
Person 4 (Notate relationship to yourself)
Person 5 (Notate relationship to yourself)
Person 6 (Notate relationship to yourself)

Please list all of the animals living in your household, in the sequence they were obtained:*

	Name	Species + Breed	Sex	Spayed/Neutered?	Age Obtained	Age Now	Quality of Relationship w Dog
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5
Pet 6

Behavior History

Please fill out the table below in regard to your dog's primary behavior concerns and other concerns you would like to address. Please include details to the problems you are noticing:*

	Details of problem - please include dates and details of recent incidents	Description of Problem	Age at which problem began
Problem 1
Problem 2
Problem 3

How have the problems progressed over time? For example: "occasionally urinated on the carpet at 2 years of age, but stopped using the box entirely a year later."*
Has the frequency or the intensity of the occurrence of the behavior changed since the problem started?*

YesNo
If yes, how and when?

BACKGROUND INFORMATION
How long have you had your dog?*
How old was your dog when you first acquired them?*
If unknown, please make best guess.
Where did you get your dog from?*
What was the reason you acquired your dog? *
Has your dog had other owners?*

YesNo
If yes, do you know why your dog was given up by previous owners?
Did you meet your dog's parents or do you have any information about littermates?*

YesNo
If yes, please describe:
Was a temperament test performed before or when you acquired your dog?*

YesNo
If yes, please describe the results:
Briefly describe your dog's behavior as a puppy:*
i.e. activity level, response to instructions, etc.

	Frequent Visitors	Occasional Visitors	Rare Visitors	Repair/Delivery Persons
Describe Response

ENVIRONMENT
What type of area do you live in? (ex: urban, suburban, etc.)*
What type of home do you live in? (ex: studio, apartment, house, etc.)*
Do you have a yard?*

YesNo
If yes, what type of fence do you have?
What is the height of your fence?
Has your house changed at all since you acquired your dog?*

YesNo
If yes, how?

DIET AND FEEDING
What do you feed your dog? (Please be specific, i.e. brand name, canned vs. dry)*
How many meals is your dog fed each day?*
Where is your dog’s food bowl located?*
If other animals eat at the same time, describe the arrangement (ie. same room, separate rooms, etc)
Does your dog typically finish each meal?*

YesNo
Does someone have to be present for your dog to eat?*

YesNo
Does your dog have any food allergies or diet restrictions?*

YesNo
If yes, please describe:
Is water available to your dog 24 hours a day?*

YesNo
If no, why not?

MISCELLANEOUS
Does your dog ever mount people, dogs or objects?*

YesNo
If yes, who/what and how often?
Does your dog ever lick himself, people or inanimate objects obsessively?*

YesNo
If yes, who/what and how often?
Is your dog sensitive to having certain body parts touched or handled (especially ears and feet)?*

YesNo
If yes, which parts?
Why have you kept your dog despite your concerns about their behavior?*
Has the frequency or intensity changed since the behavior started?*

YesNo
If yes, how and when?
How do you react when your dog shows problem behaviors?*
How does your pet respond to your reaction?*

EXPECTATIONS
What are your expectations for your Behavioral Medicine appointment? *
Is there anything else you would like to add about your pet's behavior? *
If you feel that a map or drawing of your house and/or yard may be helpful, please upload here:

Cancelof
Should be Empty:

	Female Adults	Male Adults	Children	Specific Person	Details of Aggression	No Aggression
Petting or reaching for dog
Hugging or kissing dog
Bending over or staring at dog
Bathing, grooming or toweling dog
Disturbing dog when resting
Pushing or calling dog off furniture
Giving verbal or physical correction
Approach or interact when dog is eating
Approach/interact when dog has a bone or chew item
Putting on leash or collar
Lifting dog

	Female Adult	Male Adult	Children	Specific Person	Details	No Aggression
Petting or reaching for dog
Bending over or staring at dog
Entering your house or yard
Entering/exiting any room in home
Passing by when dog is in car
Interacting when dog is on leash
Interacting when dog is away from home
Putting on leash or collar
Running/jogging/biking

	Defecates	Urinates	Salivates	Dilates pupils	Trembles	Tucks tail	Hides	Escapes	Destroys	Vocalizes	None of these responses
Home with family member
Home alone
Home with family, but seperated
Home alone confined to crate
Fireworks
Thunder
Loud noises
Flashes of light

	Check box, if recommended or attempted	Outcome? (ex: aggression, fearful, improved behavior, worsened behavior)
Stare at or "stare down"
Grab jowl/scruff +/- shake
Shake/throw can
Step on leash or choke collar and force down
"Time out" (If done, specify where, when and for how long)
Metal choke or pronged collar
Water pistol/spray
Halt or gentle leader head collar
No pull harness (ie. Easy Walk)
Bark or remote-activated shock collar
Invisible/electric fence
Citronella spray collar
Forced exposure to frightened stimuli
Knee dog in chest/belly for jumping
Hit or kick dog
Growl at dog
"String up" or hang by leash or collar
Rub dog's nose in urine, feces, or destruction
Tie or tether on short lead hooked onto wall or floor
Yell "no" at dog
"Alpha role" (hold on back, put down on back)
"Dominance down" (hold on side, legs extended, head flat)
Crate
Sit or lie down for extended period of time
Agility or other sport activity
Use of food or puzzle toys (Kongs, etc.)
Praise for good behavior
Food reward for good behavior
Kennel outdoors
Tie or tether out on a line in yard
Use of muzzle at home or on walks
Teach dog "look" or "watch me"
Increase play/exercise
Clicker training
Avoidance of stimuli that triggers fear or aggression
Feed meals by hand
Remove food bowl while eating
Pheromones (DAP, Comfort Zone)
Anything else you've tried?

	Name of Medication	Strength of medication	How many pills are given per dose?	How often do they receive this medication?
Medication #1
Medication #2
Medication #3
Medication #4

Canine Behavior Consult Request & Questionnaire

Client Contact Information

Your Pet's Information

Referral Information

HOME ENVIRONMENT

Behavior History

BACKGROUND INFORMATION

INTERACTIONS & RESPONSES

Interactions With Other Animals

Interactions With Household Members

Interactions With Non-Household Members

What Is Your Dog's Response to Visitors?

Response to Attempted Corrections

ENVIRONMENT

DAILY SCHEDULE

DIET AND FEEDING

MEDICAL HISTORY

TRAINING

MISCELLANEOUS

BITE HISTORY

EXPECTATIONS

	Date	Diagnosis	Treatment (including medications and dosage)	Outcome
Diagnosis #1
Diagnosis #2
Diagnosis #3
Diagnosis #4
Diagnosis #5