Study Participation Contact Form
Clinical Behavior Trial
I am interested in participating!
Please complete the short questionnaire below.
Your Name
*
First Name
Last Name
Your Phone Number
*
Please enter a valid phone number.
Your Email
*
example@example.com
Your Dog's Name:
*
Your dog's name
Please approximate your Dog's weight:
*
In order to qualify for Study participation, your Dog must weigh between 11-66 lbs (5-30kgs)
Is this approximate weight in lbs (pounds), or kg (kilograms)?
*
lbs (pounds)
kg (kilograms)
To your knowledge, has your Dog's weight fluctuated drastically since last recorded by his/her veterinarian?
*
yes
no
Other
Name of your Dog's primary veterinary care provider and location:
*
Hospital/Clinic Name, City etc.
Email of your Dog's primary veterinary care clinic or hospital:
*
example@example.com
If approved for the study, do you grant Animal Behavior Wellness Center permission to access your Dog's medical history from the veterinary practice stated above?
*
yes
no
Other
Is your dog older than 1 year of age, and younger than 8 years of age?
*
Yes
No
My Dog's age is:
*
Age in years
What is your Dog's birthday?
*
-
Month
-
Day
Year
Date
Has your Dog ever been prescribed medications for their behavior?
*
Yes
No
What behavior medication(s) and for what purpose have they been prescribed?
*
Name of medication
Purpose
Medication 1
just for grooming & vet visits
just for vet visits
daily anxiety
post surgery/recovery
other
Medication 2
just for grooming & vet visits
just for vet visits
daily anxiety
post surgery/recovery
other
Medication 3
just for grooming & vet visits
just for vet visits
daily anxiety
post surgery/recovery
other
Medication 4
just for grooming & vet visits
just for vet visits
daily anxiety
post surgery/recovery
other
How many dogs live in your home?
*
number of dogs
Does your Dog present with the following behaviors when left alone? NOTE: these questions pertain to behavior presented specifically when your Dog is separated from you (owner/owners).
*
OBSERVATION & FREQUENCY
1.) Panting when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
2.) House soiling when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
3.) Vomiting when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
4.) Destructive behavior when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
5.) Vocalization when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
6.) Salivation when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
7.) Restlessness (pacing, running around, etc.) when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
8.) Hiding when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
9.) Cowering when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
10.) Shaking/trembling when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
11.) Vigilance/scanning of environment when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
12.) Freezing to the spot when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
13.) Self harm when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
14.) Escape behavior when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
15.) Aggression when separated from owner(s).
YES, ALWAYS - 100% of the time
YES, MOSTLY - < 100% but > 60% of the time
YES, CONSISTENTLY - 40%-60% of the time
YES, SELDOM - > 0% but < 40% of the time
NO, NEVER - 0% of the time
DON'T KNOW
If destructive behavior is observed, what does the dog destroy?
If self harm, escape behavior, and/or aggression is observed, please share with me more details surrounding these behaviors, such as intensity and what happened:
If the answer is YES for any of the above responses, what is the timing of the onset of behaviors (if known)?
within 5 minutes
more than 5 minutes, but less than 30 minutes
more than 30 minutes, but less than one hour
more than one hour, but less than 3 hours
only after several hours
Submit
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