Weber Animal Behavior
Canine Behavior History Form
How did you hear about Weber Animal Behavior?
Guardian Information
Legal Owner Full Name:
First Name
Last Name
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Other guardian/caregiver name:
Other guardian/caregiver email:
example@example.com
Other guardian/caregiver phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
House color and parking instructions (for home visits):
Animal Information
Dog's name:
Breed or mix:
Current age:
Sex and neuter status:
Male
Neutered male
Female
Spayed female
Is this your first dog?
Yes
No
No, but it has been a while (e.g., I had dogs while growing up)
Where did you get the dog?
Rescue/Shelter
Breeder
Friend/relative
Stray
Other
How long has the dog lived with you?
What do you know about the dog's previous history?
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Family Makeup
Describe all humans in the dog's life:
Rows
Name
Age
Pronouns
Relationship (live together, visit frequently, recently gone/passed, get along, conflict, etc.)
1
2
3
4
Describe all animals in the dog's life:
Rows
Name
Age
Species (dog, cat, bird, etc.)
Relationship (live together, visit frequently, recently gone/passed, get along, conflict, etc.)
1
2
3
4
Are any other pets directly involved in the concerning behaviors?
No
Yes
Other pets directly involved:
Rows
Name
Breed/mix
Sex and neuter status
Where pet came from
Known history
How long with you
1
2
3
4
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Veterinary & Health Information
Do you have pet insurance?
Yes
No
Name of your vet clinic and/or preferred veterinarian:
Date of last vet visit:
 -
Month
 -
Day
Year
Date
Describe any recommendations given by the veterinarian for your concerns:
List any current, recent, and past medical issues or injuries:
List any medications or supplements:
List any food or environmental sensitivities or allergies:
What brand/kind of food do you feed?
Describe your feeding routine (check all that apply):
Fed at scheduled times, finishes right away
Fed at scheduled time, grazes throughout the day
Food is always available
Dry kibble
Canned
Raw or homemade
Scraps or leftover people food
Other
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Behavior History
Describe the problem behavior(s) and indicate which one concerns you the most:
Regarding the behavior that concerns you the most, when did you first notice the behavior?
Is the behavior predictable or are there any specific triggers?
How often does the behavior occur?
Several times per day
Once per day
Several times per week
Once per week
Several times per month
Randomly
Only in specific situations
Only once or twice
Other
Have you had this problem with any previous or other pets?
Yes
No
I don't know
Have you sought advice for this problem before?
What specifically have you done to try and prevent and/or resolve the behavior?
How did the behaviors change in response to what you described above?
Got worse
Got better
No change
Uncertain
Other
Please list any trainers you have worked with in the past:
Are you prepared for it to take time to resolve the problem behavior, up to several months or longer?
Yes
No
Undecided/uncertain
Have you considered other options, if the problem behavior cannot be resolved to your satisfaction?
I will do whatever it takes
I have considered (or am considering) giving up the dog
Undecided/uncertain
Have there been any changes to the home recently?
No
Addition of a baby
Remodel or worker in home
New job
Change in routine
New pet
Other
How often do you play with or exercise your dog?
Multiple times per day
Daily
Sometimes
Rarely
My dog doesn't play
Describe playtime/exercise with your dog (type of exercise, amount, and intensity):
Is your dog indoor or outdoor?
Indoor only
Indoor/outdoor with supervision
Indoor/outdoor unsupervised
Outdoor only
Other
How do you typically reward good/wanted behaviors?
Petting
Verbal praise
Treats/food
Toys/play
I don't know
Other
How do you typically punish bad/unwanted behaviors?
Physically (spanking, nose tap, etc.)
Verbally (scold, "no!", "tsst!", etc.)
Noise, clapping, penny can, or squirt bottle
Leash jerk or pop
Electronic collar
Redirection
I don't know
Other
Number of hours per day you typically spend at home:
Describe your typical day:
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House Soiling Information
Is your dog having house soiling issues?
Yes or sometimes
No (unless rare circumstances like illness)
Where is your dog eliminating?
In the crate
Tile or linoleum
Hardwood or laminate
Carpet
Laundry, blankets, or throw rugs
Furniture or bedding
Other
What is your dog doing?
Hiding from me
Lifting leg to urinate
Eating feces
Chewing on or dragging hind end
Other
Describe the elimination:
Moderate to large urine puddles
Drops of urine
Larger than expected bowel movements
Particularly smelly bowel movements
Other
Aggressive Behavior
Has your dog growled, air snapped, attempted to bite, or bitten?
Yes
No
Which of the following have you seen?
Air snap, no contact
Bruising or skin dents
Scratched skin or some blood
Shallow puncture(s)
Deep puncture(s)
Multiple bites in one incident
Medical attention required for victim
Other
Who has the aggression been directed toward?
Adult
Child
Cat
Dog
Member of the househood
Visitor or "friend" (familiar to the dog, but not living in household)
Stranger
Other
When is the aggression occurring?
During petting
During handling or restraint
During play
When walking past
When getting too close
Around mealtime
Randomly
In the home
Outdoors
At the vet or groomer
Other
Where is the aggression occurring?
Inside the home
Out of house windows or doors
Outside on the property
When leash walking
When off leash
When in the car
When away from home
At the vet, groomer, etc.
Other
Describe the circumstances of the most severe incident:
Please provide any additional information you feel is relevant:
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Agreement, Waiver, and Release
Please review the Terms and Conditions as well as the Policies and Expectations below by clicking on the links. Check both boxes to accept and proceed.
Please review the Policies and Expectations page on the Weber Animal Behavior and sign below to accept and proceed
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