Canine Behavior Form Initial

Canine Behavior Appointment Form - Initial
Welcome to our Canine Initial Behavior Appointment Form. We look forward to working with you and your dog!

Important:

*Please press "Save" button periodically to save your responses and avoid losing your progress"

It is important to know that this form will require a lot of information and often can take between 15-20 minutes to complete. The information you provide is incredibly important to our team and we appreciate all efforts to fill this form out to the best of your ability.

After you fill this form out in its entirety, be sure to click Submit at the end of the form. You will then be directed to a confirmation page and a copy of your responses will be sent to the email you provide.

If you have submitted your form and have not heard back from our team within 72 hours OR you did not receive an email confirmation of your form submission, check your spam folder then please reach out to us directly at behavior@hickoryvet.com.
Patient's (dog's) Name*
What is your dog's breed?*
How old is your dog?*
Gender*

Male NeuteredMale IntactFemale SpayedFemale Intact
Coat Color*
Dog's Date of Birth (if unknown please give approximate date):
Owner's Information
Name*

First NameLast Name
Co Owner's Name
Address*
City*
State*
Zip*
Primary Phone*
Secondary Phone
Primary Email*
example@example.com
Co-owner Primary Email:
example@example.com
Regular Veterinarian:*
Regular Veterinarian Address:*
Regular Veterinarian Phone Number: *
Regular Veterinarian Email Address*
How did you hear about us?*
(ie, Referred by Veterinarian, referred by a friend, social media, Google search, etc.)
Household Information
Do you have more people that live in your household?*

YesNo
If yes, then please list the names, ages and relationships (i.e. spouse, children) of everyone living in the household:
Are there other people in regular contact with your dog (pet sitter, housekeeper, friends, etc.)?*

YesNo
If yes, then please list the names, ages and relationships (i.e. spouse, children) of everyone in regular contact with your dog:
Are there other pets in the household?*

YesNo
If yes, then please list the names, ages, species, sex (ie. Anna, 11yo, dog spayed Female):
Type of House (single family, townhouse, condo, etc.)*
How long have you lived in this house?*
Since adoption, how many houses has your dog lived in?*
Does your home have a yard?*

YesNo
If yes, how big is the yard?
If yes, is your yard fenced?

YesNo
If your yard is fenced, describe your fence (type, height):
Acquisition History
How long have you owned this dog?*
Where did you obtain this dog?*

Performance BreederHobby BreederPrivate Home/Prev. OwnerShelter/RescuePet StoreOther
How old was the dog when acquired?*
List any behaviors of your dog's parents or litter mates (if known):
Describe any of your dog's experiences in previous homes, including fosters (if known):
Were you given any information about your dog's behavior before joining your family?*
Why did you choose this breed of dog? (coat, size, temperament, family dog, protection, etc.)*
Why did you choose this individual dog?*
Medical History
Is this dog neutered/spayed*

YesNo
If yes, at what age was your dog neutered or spayed?
What was the reason for neutering/spaying?

Population controlDog's healthCorrect existing behavior concernsUnknown/already doneOther
Did you notice any changes after neutering/spaying?*

YesNo
If yes, please describe these changes:
If your dog is *NOT* neutered or spayed, please select the reason:

Show dogPlan to breedHealth concernsOther
How much does your dog currently weigh?*
Date of most recent rabies vaccine:*
List any major illnesses or surgeries (please be sure to include dates):*
If your dog is receiving medication(s), please list below including medication name, dose, frequency given and date medication was started:
Daily Activities / Routine
Does your dog eat dry food?*

YesNo
If yes, what kind?
Does your dog eat canned food?*

YesNo
If yes, what kind?
Does your dog eat raw food?*

YesNo
If yes, what kind?
If you feed a special diet (hypoallergenic, grain free, etc.), why?*
Eating habits (check all that apply):*

Eats right awayPicky eaterGuards food from peopleGuards food from dogsGuards food from petsOther
How is your dog fed? (check all that apply)*

Fed alone (separate room/crate)Fed from slow feederFed near other petsPerson stands nearby when dog is eatingFed from food dispensing toysHand fed most mealsOther
SLEEP ROUTINE
Where does your dog sleep at night? *
Where does your dog sleep during the day? *
If disturbed when sleeping, what is your dog's reaction?*

HappyStartledGrowlsBarksBitesScaredGrumpyPlayfulOther
Have you made any changes to where your dog sleeps because of their reactions to being disturbed?*

YesNo
If yes, please describe
LIVING SPACES / BEING LEFT ALONE
Where does your dog spend most of their time when people are home?*

Loose in houseLoose in house, access to outsideConfined to part of house with gatesConfined to part of house with access to outsideInside a crate or a penLoose in yardOutside in kennel or penOther
If your dog needs to be confined in a separate space away from household members, how does your dog react?*

Relaxes (sleeps, plays with toys, is quiet)BarksHowls in beginning, then settlesHowls the whole timeTries to escape (scratches, digs, bites at barriers or crate)Barks at soundsDon't know / Don't do
If you have visitors to the house but your dog does not have access to the people, how do they react?*

Relaxes (sleeps, plays with toys, is quiet)BarksHowls in beginning, then settlesHowls the whole timeTries to escape (scratches, digs, bites at barriers or crate)Barks at soundsDon't know / Don't do
How long is your dog left alone on an average day? *
When is your dog left alone? (i.e. 8:00am - 5:00pm)*
What is your dog's reaction to being left alone? (Check all that apply)*

CalmDepressedBarks/Cries/HowlsUrinates/defecatesEscapesDestructiveAnxiousExcitedAggressive
If there will be or have recently been any major changes to the daily routine (i.e. vacations, owner who travels for business, etc.) please describe: *
EXERCISE
Does your pet get regular leash walks?*

YesNo
If yes, who takes the dog for leash walks?
How often?
How long are the walks?
Location (ie around the neighborhood, in town, park, etc.)
What do you use to walk the dog?

Plain/flat collar/martingaleProng collarChoke collar/slip leadBody harnessFront attach harnessHead collar (Gentle Leader/Halti)Remote controlled collar1'-4' Leash5'-8' LeashLonger LeashRetractable Leash
How good is your dog on leash?*

Good, does not pullFair, pulls but I can controlPoor, pulls but I can not control
Does your dog get any off leash exercise?*

YesNo
If yes, who takes the dog for off leash exercise?
How often?
How long?
What locations (ie. yard, dog park, dog daycare, hikes, etc.):
Does your dog play with any toys?*

YesNo
What are your dogs favorite toys? (Check all that apply)

BallsStuffed animalsRope toysSoft squeakyFrisbeeHard chewTug toysRubber toysOther
How does your dog play with toys?

Tug games with other dogsChase games with peopleShakes and "kills" toysTug games with other peopleChase games with other dogsChews toysOther
How often does your dog play with people?*

NeverRarelyWeeklySeveral times per week
How often does your dog play with other dogs?*

NeverRarelyWeeklySeveral times per week
TRAINING
Has your dog had any of the following training?*

Puppy class (under 6 months old)Group class (under 1 year)Group class (adult)Private classBoard and trainVirtual trainingHomeschooledOther
If you worked with a trainer, please list their name and business:
Did your dog enjoy training?

YesNo
What training techniques have you used?*

Training collar (choke)Food rewards/verbal praisePlay toysProng collarRemote collar (shock, vibrate, citronella)Bark collar (shock, vibrate, citronella)Clicker trainingOther
Who in the household trained the dog?*
What commands does your dog know? *
Has your dog won any titles (ie agility, obedience, CGC?)*

YesNo
If yes, what titles?
How well does your dog obey commands WITHOUT distraction?*

Very wellWellFairPoorDoes not follow commands
How well does your dog obey commands WITH distractions?*

Very wellWellFairPoorDoes not follow commands
How does your dog react to unfamiliar people entering your home?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to unfamiliar people walking past or approaching the house?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to unfamiliar people once in home?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to unfamiliar people away from home while off leash?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to unfamiliar people away from home while on leash?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to an unfamiliar person staring at your dog?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to people on bicycles, roller blades, etc. (while on leash)?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to joggers (while on leash)?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to cars/trucks going by while on-leash?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to babies?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to children?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to unfamiliar dogs, when your dog is on-leash?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to unfamiliar dogs while your dog is off leash?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to squirrels/cats/small animals?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to being in the yard and a person passes by outside of the yard?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to being at the veterinarian's office?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a stranger approaching when the dog is inside the car?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to loud noises?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member walking by the dog while they are eating a regular meal?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member reaching for or taking their food dish while dog eats regular meal?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member walking by while dog eats more delicious food?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member reach for / take away non-edible toy (ie ball, stuffed animal)?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member reach for / take away edible bone / rawhide?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member take away stolen non-food item (i.e. socks)?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member taking away stolen food items (including dirty tissues, paper towels, food wrappers)?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member reaching for dropped food at the same time as the dog?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member reaching over head / pet on top of the dog's head?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member petting other parts of the dog's body?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member brushing the dog?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member bathing the dog?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member picking up the dog?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member putting on or taking off the collar?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member putting on or taking off the leash?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member disturbing the dog while they are sleeping?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to a family member moving them while they are on furniture?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to sitting with a family member and another family member approaches?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to when held back when excited (ie from running out the door - NOT WHEN AGGRESSIVE)?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to when held back when showing aggression (ie barking at another dog)?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to verbal reprimands?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to leash corrections?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to physical reprimands?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to remote collar corrections?*

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
Is there another dog in the household?*

YesNo
How does your dog react to another dog in the household around regular food?

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to another dog in the household while on walks together?

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to another dog in the household around favorite people?

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to another dog in the household around toys?

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to another dog in the household around treats?

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to another dog in the household around rawhides?

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
How does your dog react to another dog in the household during play?

HappyNeutralFearful/anxious/submissiveSnarl/growlBarkSnapBiteDon't know/don't do
BITE HISTORY
Has your dog ever bitten a PERSON?*

YesNo
If yes, describe in detail when the bite happened (approx. date is okay), who was bitten and the circumstances of the bite. *Please answer separately for each bite.*
How bad was the worst bite your dog ever gave to a person (check all that apply):

Made contact but didn't leave a markSmall red markBruised, didn't break skinBroke skin, minor scrapeBroke skin, puncturesMultiple puncturesPunctures and tore fleshMultiple bites at one timeRequired emergency treatment
Have any victims threatened / taken legal action because of an aggressive incident?

YesNo
Have any bites been reported to Animal Control or other authorities?

YesNo
PRIMARY BEHAVIOR PROBLEM
What is the one main behavior problem that you want to discuss?*
Describe the very first incident of this problem (please include the date and age of your pet at the time): * Important! Please include the following in your description:
- Where the incident occurred
- who else (human/animal) was present
- what happened just before the incident
- how everyone present reacted
- If you noticed any changes in your dog's body language or facial expression before, during or after the incidents please describe
Try to remember the earliest occurence of the problem, even if it wasn't as serious as it is now. For example, if your dog is aggressive to people, describe the first time she growled or barked at someone, not the first bite. Or if your dog has problems being left home alone, describe the first time he/she whined and cried when you left, not just the first time he ripped up the carpet.
Describe below the FIRST incident of this problem: *
Describe below the most RECENT incident of this problem (please include date and age of your pet at the time): *
Describe, per instructions, at least one other incident you feel illustrates the problem behavior (if you would like to describe other incidents, that's great!): *
How frequently does this behavior occur?*

Less than once a monthLess than once a week1-6 times per week1-10 times per dayMore than 10 times per day
Is the frequency:*

IncreasingDecreasingUnchanged
When your dog is in a situation that could be potentially problematic, how often does the problem behavior occur?*

RarelySometimesOftenFrequentlyAlways
What TRAINING have you tried to do to correct this behavior problem and how did your dog respond? (example: yelled at him when he jumped on visitors and he/she started to growl)*
What MEDICATIONS have you tried to use to correct this behavior problem and how did your dog respond? (please list all medications/supplements that have been tried and your dog's reaction)*
Have you ever considered euthanasia or rehoming your dog because of this problem? (Please understand that this is not a recommendation or suggestion. It is simply important for us to understand a full picture in our assessment.)*

EuthanizeRehomeNeither
Has anyone suggested that you euthanize or rehome this dog because of the problem? (This is not a recommendation; we just want to know what has been suggested.)*

YesNo
How serious do you and each of the other members of the household find this problem (please let us know if anyone in the household is in disagreement)?*
List other problem behaviors in order of importance to you: *
Do we have permission to post pictures on our social media?*

YesNo
Please upload your favorite picture of your pet! (OPTIONAL)

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Canine Behavior Appointment Form - Initial

Owner's Information

Household Information

Acquisition History

Medical History

Daily Activities / Routine

SLEEP ROUTINE

LIVING SPACES / BEING LEFT ALONE

EXERCISE

TRAINING

BITE HISTORY

PRIMARY BEHAVIOR PROBLEM