• Canine Behavior History Form

  • Please allow 30-60 minutes to complete this form. A copy of your responses will be emailed to you once submitted.

    Please email info@vetbehaviormn.com if you have any problems with this form.  We will be happy to assist!

     

  • Your Information:

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please share how you learned about us:*
  • Your Date of Birth (If certain prescriptions are warranted, your DOB is required to dispense to you for your pet)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please share your preferred pronoun(s)*
  • What is your preferred method of communication?
  • Format: (000) 000-0000.

  • Patient Information

  • Date of Birth (estimate if unknown)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Approximate weight*
  • Where did you obtain your dog?*
  • How many previous owners has your dog had (not including breeder, but including foster caregivers)?*
  • Format: (000) 000-0000.
  • Does your pet see any other specialist veterinarian?*
  • Date Rabies vaccine was given*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Household Information

  • Please list all HUMAN members in your household (including your self). For additional adults that are owners, please list phone number and email address for communications.*
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  • Please list all PETS in the household (including the patient) in the order they were obtained. Please enter N/A if not applicable*
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  • Living Situation. Please check all that apply*
  • If in a multiple story building how do you enter/exit?*
  • Describe your yard. Please check all that apply.*
  • Describe your dog's yard access. My dog
  • Please indicate any household changes that have occurred since acquiring this pet.*
  • Do you feel your dog has been directly or indirectly impacted by changes related to the COVID-19 pandemic?*

  • Behavior Concerns

    We strive to address fear, anxiety, and/or aggression at any level. This may present subtly, such as frequent yawning, lip licking, or avoidance behaviors. Or more obviously as this growling, lunging, snapping, or biting. Our approach is designed to identify and support each animal's unique behavioral needs—whether signs are quiet or more clearly expressed. Some portions of this questionnaire may not apply to your pet, but is important insight by our team.
  • My concerns center mainly on:*

  • Bite History

  • Has your dog been declared 'Potentially Dangerous' or 'Dangerous' by any Jurisdiction?*
  • People your dog has ever been aggressive toward?*
  • Total bites to PEOPLE, where teeth have TOUCHED skin:*
  • How many of the bites to people have BROKEN skin:*
  • Bite Pattern to PEOPLE:*
  • ** If your dog has bitten a person(s), what injuries were sustained? Mark all that apply.
  • Aggression toward other pet(s):*
  • If your dog is aggressive to another pet in the home, indicate the triggering situations.*
  • Total bites to PETS, where bites have TOUCHED skin:*
  • How many bites to PETS that have BROKEN SKIN?*
  • Bite Pattern to PETS:*
  • ** If your dog has bitten another dog (or cat), what where the injuries sustained? Mark all that apply.*

  • Your Goals

  • Do you feel that your goals or expectations for your pet are attainable?*

  • Equipment & Training History

  • Please indicate equipment you used in the PAST with your dog.*
  • Please indicate equipment you CURRENTLY use with your dog:*
  • I feel that the tools/methods that I currently use are effective based on my pet's response.*
  • Training History*
  • How would you describe the training methods used?*

  • General Behavior Screening Questions

  • When your dog goes to the vet, your dog (please check all that apply):*
  • Does your dog have a crate/kennel or other place of confinement*
  • If your dog has a crate/kennel, is it:*
  • How does your dog react to their crate/kennel/room? Check all that apply.
  • Does your dog follow you (or another family member) from room to room?*
  • What does your dog do when you prepare to leave?*
  • Where is your dog when you are gone from home?*
  • Does your dog do any of the following when you are away? Please check all that apply.*
  • When your dog has been left home alone, do you typically come home to find that your dog was sleeping?*
  • Do you have a webcam in your home to observe your pet while away?*
  • Does your dog seem frantic to greet you when you return home?*
  • Does your dog exhibit any of the following to the point of interfering with normal function?*
  • How does your dog respond to the following? Please indicate all that apply.
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  • What is the longest period of time it has ever taken your dog to recover after a noise event?*
  • What best describes your dog's sleeping patterns:*
  • Which behaviors do you observe when you have a GUEST to your home?
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  • How does your dog handle traveling in the car?*
  • If you or another family member approach your dog when they have the listed resource, which behaviors do you observe?
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  • If you or another family member handle your dog, which behaviors do you observe?
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  • Indicate your dog's response on walks or other times they see an unfamiliar PERSON:
    Rows
  • Indicate your dog's response on walks or other times they see an unfamiliar DOG:
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  • Diet & Feeding

  • Does your dog have any diet restrictions?*
  • How often do you offer food?*
  • Does your dog finish all of the food?*

  • Medication & Major Medical History

  • Is your dog currently on any medications or supplements?*
  • Please list current medications and supplements your dog receives, OTHER THAN FOR BEHAVIOR. (if not applicable, enter N/A in box 1)
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  • Please list current medications your dog receives as prescribed specifically for BEHAVIOR (if not applicable, enter N/A in box 1)
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  • Has your dog ever been prescribed behavior medications in the past?*

  • Your Sentiments

  • We understand having a pet experiencing behavior challenges can be difficult. We would like to know and understand more about your relationship with your pet. Please describe your relationship with your pet. Check all that apply.*
  • What are your feelings on the potential use of medications IF recommended as part of your pet's treatment plan?*
  • Ongoing behavior therapy is often recommended as part of a patient's treatment plan. Do you have an interest in pursuing ongoing foundational skills / behavior therapy beyond meeting with the doctor?.*
  • Are you considering finding another home for your dog due to behavior concerns?*
  • If yes or maybe, is this something you would like to discuss during your appointment?*
  • Are you considering euthanasia due to behavior concerns?*
  • If yes or maybe, is this something you would like to discuss during your appointment?*
  • Has anyone told you you should euthanize your dog?*

  • For all in-clinic visits:

    We strongly recommend that all primary adult caregivers in the household, including spouses, partners, and other significant caretakers, attend the initial diagnostic, assessment, and treatment planning appointment. If teenagers are substantially involved in the pet’s daily care or interactions, their participation at this initial visit is also encouraged. Ensuring that all key members are present supports a unified understanding of the diagnosis, recommendations, and behavior modification plan from the outset. If all parties are unable to attend in person, we are happy to provide a Zoom meeting link so those who cannot be physically present may participate remotely.
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