Canine History Form

New Patient History Form - Canine

Thank you for scheduling a behavioral medicine consultation for your pet. Veterinary Behavior Solutions is committed to providing excellent specialty care for your pet's behavioral needs.

The following form will help us gather information about your pet's lifestyle and behavior prior to your pet's appointment. If you do not understand any of the questions or do not feel comfortable answering a question, feel free to make that notation.

Please return this form to us at least 48 hours prior to your appointment. The form will be automatically submitted to us if you follow the form all the way through to the end. If you prefer to print out a copy, please submit it through email (info@vetbehaviorsolutions.com) or by fax (877.240.4543). DO NOT MAIL THE FORM.

All family members over the age of 5 who are involved with your pet are welcome to attend the consultation. Please allow a full two hours for the consultation. You may additionally contact us about bringing companion pets to the consultation if they are involved in the behavior problem.If you have other requests, please contact us by phone or email to discuss your specific situation at 877.203.5973 or info@vetbehaviorsolutions.com.

If you are concerned about the safety of you, a family member or other pets in the household prior to your consultation, please contact us immediately for further guidance.

We are looking forward to working with you and your pet!

Dr. Beth Strickler and the staff of Veterinary Behavior Solutions

Phone:877.203.5973
Email: info@vetbehaviorsolutions.com
Fax: 877.240.4543

Canine History Form
The information you provide below will be used during your consultation to develop a diagnosis and plan of treatment. Please fill it out as completely as you can. All information will be held in strict confidence and will not be released to any third party without your written consent.

Please submit this form online at least 2 business days prior to your dog's appointment
Today's Date*

MonthDayYear
Date
Your Contact Information*

First NameLast Name
Preferred Pronouns
Spouse / Partner Name

First NameLast Name
Preferred Pronouns
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Phone Number*

Area CodePhone Number
Whose phone number is this?*
Secondary Phone Number

Area CodePhone Number
Whose phone number is this?
Additional Phone Number

Area CodePhone Number
Whose phone number is this?
E-mail*
Secondary email:
How best do you learn new information?

VerbalVisualBoth

Your Family Veterinarian's Contact Information
Family Veterinarian*
Hospital Name*
Hospital Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Hospital Email*
Do you authorize us to send a summary of the consultation to your family veterinarian?*

YesNoI would like to discuss this further at the consultationOther

	NR	M	B	G	SL	SN	BT	ND
Take dog’s meal away while he/she is eating
Add food to bowl while dog is eating
Take away dog's favorite toy
Pet the dog
Trim dog's nails
Lift or try to lift the dog
Grab dog by collar
Hug or kiss dog
Scold dog verbally
Restrain dog
Push on dog's back
Bathe dog
Push on dog's rump
Wash dog's face
Wake dog when sleeping

Canine History Form

Your Family Veterinarian's Contact Information

Your Dog's Information

Behavior History

Medical History

Your Dog's Environment

Diet and Feeding

Your Dog's Daily Routine

Other Animals

Training

Your Dog's Interaction with People