Veterinary Behavior Specialties of MN Canine Patient History Form

Canine Behavior History Form

Your Information:

Patient Information

Household Information

Behavior Concerns

Bite History

Your Goals

Equipment & Training History

General Behavior Screening Questions

Diet & Feeding

Medication & Major Medical History

Your Sentiments

For all in-clinic visits:

Canine Behavior History Form
Please allow 30-45 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:
Email*
example@example.com
Today's Date*

MonthDayYear
Date
Vet ReferralTrainer ReferralFriend/Family/Co-workerOnline SearchSocial MediaOther
Your Name*

First NameLast Name
Your Date of Birth (If certain prescriptions are warranted, your DOB is required to dispense to you for your pet)

MonthDayYear
Date
He/Him/HisShe/Her/HersThey/Them/TheirsOtherI prefer not to answer
EmailTextScheduled phone call/zoom consultation (Additional fee applies)
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Patient Information
Patient's Name:*
Breed:*
Date of Birth (estimate if unknown)*

MonthDayYear
Date
Female SpayedMale NeuteredFemale IntactMale Intact
<10lbs11-20lbs21-50lbs51-100lbs>100lbs
BreederFoster Based RescueShelterNewspaper/Internet AdFriend/Family/Co-workerPet StoreOther
Please list name of Breeder, Rescue or Shelter.
How long have you had this dog/date arrived in your home?*
How old was your dog when they joined your household?*
01234 or moreUnknown
Name of Primary Care Clinic:*
Primary Clinic Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Clinic Email:
example@example.com
Name of Primary Veterinarian:*
Does not applyDermatologySports Medicine and RehabilitationNeurologyOphthalmologyCardiologyOther
If so, who? Name of Veterinarian and practice phone number +/- email:
Please list any previous veterinary clinics your pet has been seen at*
Is your pet current on the Rabies vaccination?*
Rabies is a public health risk. This is considered a core vaccination for all patients. We require all patients are current on their rabies vaccine in order to be seen. IF your pet is unable to receive the vaccination, please contact us to discuss alternatives.
Date Rabies vaccine was given*

MonthDayYear
Date
Hospital/Clinic Rabies vaccination was given?*

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.*

If more than 5 members, please add additional HUMAN household members below:

Please list all PETS in the household (including the patient) in the order they were obtained. Please enter N/A if not applicable*

If more than 5 household PETS, please add additional pet members here:
Single family homeMultiple story Apartment/CondoTownhouse/Patio home/4-Plex2-Level Duplex - Upper2-Level Duplex - LowerUrbanSuburbanRuralLiving situation varies with the seasonLiving situation varies depending on family needs
ElevatorPrivate entryPass through hallwaysCommunity lobbyOther
No yardUnfenced yardPrivacy FenceChain link fence (or other type of fence dog can see through)Underground/electronic 'fence'Other
has unlimited, unmonitored access to the yard 24/7 through a dog doorhas unlimited, unmonitored access to the yard 24/7 through a dog door only when an adult member is homehas a way to request access to the yard space and is allowed out unmonitoredhas a way to request access and is allowed out while monitored from inside the househas a way to request access and is allowed out while monitored while outside with dogis let out at regular intervals throughout the day and unmonitoredis let out at regular intervals throughout the day and directly monitoredonly goes outside on a leash with handlerOther
Serious illness of you or family memberDeath of a human in householdDeath of a pet in householdDivorceBlended householdMarriagePregnancyBaby BornChild moved in or outOther pets moved in or outPet permanently addedFamily MovedFamily schedule changed (lost/gained jobs, school started/ended)NoneOther
YesNoMaybe
If you answered 'yes' or 'maybe' to the previous question, please explain:

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.
Aggression to family membersAggression to a child in my homeAggression to people NOT living in my homeAggression to children NOT living in my homeReactions/aggression to dogs NOT living in my homeAggression between the dogs in my homeAggression to other animals in my homeAggression to other animals NOT in my homeMy dog's overall anxietyMy dog's profound fear/reclusivenessMy dog's specific fears/phobias/anxietiesMy dog's behaviors at the vet clinicOther
Concern #1 The main reason you are seeking help today*
Approximate or actual date or age problem began. After any particular incident?*
Concern #1
Example A: Description of event. Please include the approximate date, what happened, where it happened, who was present (include people and other animals if applicable), and what happened after. PLEASE BE AS DESCRIPTIVE AS POSSIBLE, THIS IS AN EXTREMELY IMPORTANT PORTION OF THE HISTORY*
Concern #1
Example B: Description of event. Please include the approximate date, what happened, where it happened, who was present (include people and other animals if applicable), and what happened after. PLEASE BE AS DESCRIPTIVE AS POSSIBLE, THIS IS AN EXTREMELY IMPORTANT PORTION OF THE HISTORY*
Concern #1
Concern #2
Approximate or actual date or age problem began. After any particular incident?
Concern #2
Example A: Description of event. Please include the approximate date, what happened, where it happened, who was present (include people and other animals if applicable), and what happened after. PLEASE BE AS DESCRIPTIVE AS POSSIBLE, THIS IS AN EXTREMELY IMPORTANT PORTION OF THE HISTORY
Concern #2
Example B: Description of event. Please include the approximate date, what happened, where it happened, who was present (include people and other animals if applicable), and what happened after. PLEASE BE AS DESCRIPTIVE AS POSSIBLE, THIS IS AN EXTREMELY IMPORTANT PORTION OF THE HISTORY
Concern #2
Concern #3
Approximate or actual date or age problem began. After any particular incident?
Concern #3
Example A: Description of event. Please include the approximate date, what happened, where it happened, who was present (include people and other animals if applicable), and what happened after. PLEASE BE AS DESCRIPTIVE AS POSSIBLE, THIS IS AN EXTREMELY IMPORTANT PORTION OF THE HISTORY
Concern #3
Example B: Description of event. Please include the approximate date, what happened, where it happened, who was present (include people and other animals if applicable), and what happened after. PLEASE BE AS DESCRIPTIVE AS POSSIBLE, THIS IS AN EXTREMELY IMPORTANT PORTION OF THE HISTORY
Concern #3

Bite History
YesNoMaybe - Is pendingN/A
If you answered 'yes' or 'pending' to the above question, please give municipality/jurisdiction:
Does not applyAdults living in the homeAdults not living in the homeChildren living in the homeChildren not living in the homeVeterinarian/Veterinary StaffGroomerTrainerDelivery people/mail carrierOther
0123456-1011-20Over 20
0123456-1011-20>20
N/A'Air snap' only - no contactSnap then releaseBite and holdMultiple rapid bites
No injuryRed markBruisingShallow punctureDeep punctureSuperficial laceration(s) or scratch(es) -- no stitches, glue, staples, etc requiredLaceration that needed 1 or more staples/stitches to closeInjury in a single location on bodyInjury to multiple body locations in single incidentInjury that did NOT require medical care from a health professionalInjury that required medical care from a health professional
Does not applyDogs not living in the homeDogs living in the homeOther pets/cats living in the homeOther
Food bowlDropped human foodBones, rawhides, chews, treatsNon-edible toysWhen the other dog is receiving attentionWhen on couch or bed (dog's or human's)When one or both dogs are excited or agitatedAs the other dog passes through a doorway/hallwayUpon seeing or hearing the other dogOther
0123456-1011-20>20
0123456-1011-20>20
N/ASnap then releaseBite and holdMultiple rapid bites
N/ANo injuryRed markBruisingShallow puncturesDeep puncturesSuperficial laceration(s) or scratch(es) -- no stitches, staples, glue, etc requiredlaceration(s) that needed 1 or more stitches/ staples etc to closeinjury to a single location on bodyinjury to multiple locations on body from the same aggressive incidentinjury that did NOT require medical care from a veterinary health professionalinjury that required medical care from a veterinary health professional

Your Goals
What are your goals for visiting our clinic, for your pet?*
YesNoMaybeThat depends partly on the assessment resulting from this appointment
When is your dog most happy?*
When is your dog least happy?*
When is your dog most calm?*
When is your dog most stressed?*

Equipment & Training History
Flat buckle collarMartingale collarChoke collarProng collarHarnessHead halter (ex. Gentle Leader, Halti)Bark-activated shock collarUnderground/electronic 'fence' collarRemote-activated shock/training collarRetractable leashBasket or cage type muzzleFabric or mesh muzzle (that holds the mouth closed)Other
Flat buckle collarMartingale collarChoke collarProng collarHarnessHead halter (ex. Gentle Leader, Halti)Bark-activated shock collarUnderground/electronic 'fence' collarRemote-activated shock/training collarRetractable leashBasket or cage type muzzleFabric or mesh muzzle (that holds the mouth closed)
Yes, I want to continue to use my current training tools/methods.No, the tools I'm currently using are not working, and I'm eager to make changes to my tools/methods.Maybe, I'm open to discussion about alternative training tools/methods.
No school, trained yourselfPuppy classesGroup classesAgility or other dog sportsPrivate trainer in homeSent away to trainerReactive dog classesOther
Name of trainer(s) or training business:*
Training Experience: What was most beneficial/helpful?*
Training Experience: Were there any recommendations or skills that you felt made your pet's concerns or behaviors worse?*
All reward based - reinforcement for desired behaviors primarily with food rewardsA mix of rewards and 'corrections' for undesired behaviorsMostly corrective/punishment basedOther

General Behavior Screening Questions
is eager to go into the building and happy to see the veterinarian and staffis terrified to go into the building - balks/resists going in the doorwillingly goes in to the building but shows signs of fear/anxietybarks at or is aggressive toward other people/dogsshrinks away or hides from veterinary staff/veterinarianis aggressive toward veterinary staff/veterinarianI don't know how my dog behaves in the building due to COVID-related 'curbside' appointmentsI have concerns about how my dog is handledOther
YesNo
WirePlasticOther material
Does your dog have a place of confinement other than a crate/kennel?*
Ex. Laundry Room, Kitchen with gate, etc
My dog spends time inside on their ownMy dog has to be gently nudged or told to go into it, but is compliantMy dog resists being confined - hides or becomes aggressiveMy dog is very anxious/distressed when confinedMy dog runs right in, anticipates when I want them to go inMy dog has no place of confinementOther
YesNoSometimes
Follows youWhinesPantsTremblesHidesBlocks you from leavingLies down on bed/couchIs asked to go to place of confinementRuns into place of confinement/anticipatesNothing/stays where they are
Confined to a crate/kennel with door closedConfined to a separate room(s)Loose in the houseIn an outdoor kennelOutside in fenced yardTethered outsideBoth in and outside the house/has access to outdoors through doggy doorAt doggy daycare or other location away from home
Urinate in the houseDefecate in the houseDestruction to the homeBark, whine, howlNone of the above
YesNoSometimes
YesNoOther
YesNoSometimesSeems happy to greet me but not over-the-top frantic
Focused attention on/staring at light/reflections or shadowsTail chasing/spinningFlank sucking (literally sucking on the fold of skin between the rear leg and the body)Snapping at the air/"imaginary flies"Pouncing at the groundNone of the above

How does your dog respond to the following? Please indicate all that apply.

Rows	Tremble	Pant	Hide/Move Away	Bark/Growl	No Reaction	Whine	Pace/fidget	Salivate/drool	N/A
Thunderstorm
Firework
Any sudden loud sound
Household noises - beeps and other
Smoke alarm or low battery beep
Motor vehicles passing by on walk
Noise outside the house
People and/or dogs passing by the house
Delivery trucks

Recovers as noise ends5-10 minutes15-30 minutesSeveral hoursSeveral days
Describe other sounds/noise events that elicit a response from your dog (if applicable):
Where does your dog sleep at night?*
only sleeps deeply overnight and not at all during the daysleeps deeply overnight and rests but may not be sleeping during the daysleeps deeply overnight but seems to sleep "with one eye open" during the daysleeps deeply overnight and only seems to sleep deeply during the day when home alonesleeps deeply overnight but won't sleep during the day if home alonesleeps deeply overnight but only sleeps deeply for 10-15 minutes a few times during the daysleeps deeply during the day and has difficulty sleeping overnightsleeps or rests between 18-22 hours over the course of a day/night cycleOther
Where is your dog when you have guests to your home?*

Which behaviors do you observe when you have a GUEST to your home?

Rows	Friendly, may bark	Runs away/hides	Moves away, barks	Moves towards, barks	Worry may bite	Has bitten	Purposefully avoid access to guest
Enters home
Looks at dog
Reached for/Tries to pet

calm, lies down, goes to sleeplooks out the window, but is calmdoes not want to get into the carpantingrestlessnesstremblingbarks at people, dogs, other stimuli outside the vehicleexcessive droolingvomiting

If you or another family member approach your dog when they have the listed resource, which behaviors do you observe?

Rows	We intentionally do not approach	No reaction	Growl	Bare Teeth	Snap - no contact	Bite w/contact	N/A
Eating from bowl
Bone, rawhide
Toy
'Stolen item'
On dog bed
On human bed/furniture

If you or another family member handle your dog, which behaviors do you observe?

Rows	We intentionally avoid this	No reaction	Growl	Bare teeth	Snap - no contact	Bite w/contact	Back away/try to leave
Feet wiped
Handling/touching of body
Moved off bed/couch
Disturbed while sleeping
Physically moved
Putting on/off: harness/collar/ leash
Verbally scolded
Physically punished

Indicate your dog's response on walks or other times they see an unfamiliar PERSON:

Rows	N/A	Football field away	Block away	10 feet away	Very near
Watchfulness
Tense
Bark
Pulling on leash - not sure if friendly or not
Aggresively Lunges
Snap/Bite
Over-excited, but friendly
Tries to pull/run away from person

Indicate your dog's response on walks or other times they see an unfamiliar DOG:

Rows	N/A	Football field away	Block away	10 feet away	Very near
Watchfulness
Tense
Bark
Pulling on Leash - not sure if friendly or not
Aggressively lunges
Snap/Bite
Over-excited, jumping, but friendly
Tries to pull/run away from

Diet & Feeding
YesNo
If yes, please describe:
What type of food or brand of food do you feed? Please be specific*
Brand and Flavor ie. Science Diet Lamb & Rice
Once dailyTwice dailyThree times dailyFree choice
AlwaysSometimesSkips meals/doesn't finish meal once per week to monthSkips meals/doesn't finish meal dailyOther

Medication & Major Medical History
YesNo

Please list current medications and supplements your dog receives, OTHER THAN FOR BEHAVIOR. (if not applicable, enter N/A in box 1)

Please list current medications your dog receives as prescribed specifically for BEHAVIOR (if not applicable, enter N/A in box 1)

Please describe your observations of change/response in your dog's behavior to CURRENT medication(s):*
YesNo
Please list any PAST/DISCONTINUED BEHAVIOR MEDICATIONS and your observations of change/response in your dog's behavior for each medication listed.
Please list your dog's major medical procedures and illnesses: *
Ex. Knee/stifle surgery, recurrent ear infections, allergies, lameness.

Your Sentiments
My dog is a member of the familyI enjoy spending time and/or playing with my dog.I love my dog, but their behavior causes strain in our relationship, and my/my family's quality of life.I am frequently frustrated by my dog's behavior, and it causes moderate to significant difficulty bonding with my pet.I do not feel bonded to my dog.I am stressed over concerns for my dog(s) quality of life.Other
Using the scale below, with 1 being least affected and 5 being most affected, how would you rate the degree to which your dog's behaviors affect your quality of life and your relationship with your dog.*

1

2

3

4

5

1 is Least , 5 is Most
I am against the use of medication(s) and do not want to use medication(s) on my pet.I am unsure about utilizing medication(s). I would need to learn more about the medication(s), the potential benefits, side effects and long-term prognosis with their use.I'm okay with utilizing medication(s) if medically recommended/warranted by the doctor, for use on my pet.Other
If you responded 'other', please share with us your sentiments or concerns about medication(s).
YesNoMaybeDepends on costDepends on how much time it takes
YesNoMaybe
YesNoMaybeN/A
YesNoMaybe
YesNoN/A
YesNo
If yes, who?
What else has been tried so far to improve the situation?*
Please tell us anything else you feel we should know.

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.
How many people will be attending the appointment with the doctor in-person?*
How many people will be attending the appointment with the doctor via Zoom?*
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Should be Empty:

Relationship to You

Occupation

Phone Number

Member 1 (self)