Brief Screening Questionnaire

Owner Information
First Name
Last Name
Address
E-mail address
example@example.com
Phone number
Format: (000) 000-0000.
Patient Information
Name
Species (Canine/Feline)
Breed
Sex (please indicate if spayed/neutered)
Age
Colour
Weight
Medical Alerts
Current or Past Health Problems

0/250
Current Medication(s)

0/250
Primary Veterinarian & Previous Medical History
Name of Clinic
Clinic Address
Clinic E-mail address
example@example.com
Clinic Phone Number
Format: (000) 000-0000.
Veterinarian
Medical History (any other information not mentioned above)
Screening Questionnaire
1. a) Age of your dog (weeks, months or years) when they were adopted:
1. b) How many owners has your dog had?
1. c) How long have you had this dog?:
2) Age in weeks at which your dog was definitively housetrained (e.g., no accidents in the house). If you adopted your dog as an adult and the dog was house trained, just put in the adoption age:

0/85
3) What type of training does your dog have? (ex: puppy class, trained at home, private or group classes)

0/85
4) What do you walk your dog with? (Ex: flat collar, prong, slip lead, harness, choke chain, head halti)

0/85
5) Please list the behaviour(s) of concern for your visit today:
a)
b)
c)
d)
e)
6) For each behaviour of concern:
a) How frequently does it occur (and when)? When did it start? Has it changed over time?

0/35
b) How frequently does it occur (and when)? When did it start? Has it changed over time?

0/25
c) How frequently does it occur (and when)? When did it start? Has it changed over time?

0/30
d) How frequently does it occur (and when)? When did it start? Has it changed over time?

0/40
e) How frequently does it occur (and when)? When did it start? Has it changed over time?

0/40
f) How frequently does it occur (and when)? When did it start? Has it changed over time?
g) What have you tried to do to help resolve the issue(s)?
7) Do you have any problems, complaints or concerns with:
i) Urine or feces inside the house
ii) Does your dog "mark" with urine or feces?
iii) Does your dog experience periodic bouts of diarrhea?
iv) Did your dog destroy any objects that were not toys while teething?
v) Does your dog destroy any objects or anything else (doors, windows, et cetera) now?
vi) Does your dog mouth anything or anyone?
vii) Does your dog exhibit any vocalization about which you are concerned?
viii) Does your dog show any signs of growling, barking, snarling, or biting?
ix) Have you ever been concerned that your dog is "aggressive" to people?
x) Have you ever been concerned that your dog is "aggressive" to dogs?
xi) Have you ever been concerned that your dog is "aggressive" to animals other than dogs?
xii) Has your dog ever bitten anyone, regardless of circumstances?
xiii. Has your dog had any changes in:
a. Sleep habits:
b. Eating habits:
c. The ability to get around or jump on the bed or furniture?
d. Grooming behaviour or coat appearance:
e. Has anyone ever told you that they were afraid of your dog?
8) Is there anything else you would like more information about or you think we should know?
0/300
Should be Empty:

Owner Information

Patient Information

Medical Alerts

Primary Veterinarian & Previous Medical History

Screening Questionnaire