Dog Behavior Questionnaire
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred method for a virtual consultation
Please Select
Phone call
Zoom
Webex
Pets Name:
Number of adults in the household (>18 years):
Number of children:
Ages of children:
Number of dogs in the house (including the patient):
Number of cats in the house:
Number of other animals:
Who is the primary caretaker of the dog?
Please list all pets in the household: Name, breed, sex, age
Current medications, vitamins, or supplements:
Origin (Select one):
Own breeding
Pet Shop
Breeder
Private Home
Shelter/Rescue
Stray
Other
Don’t Know
Age removed from litter (If unknown please write “unknown”):
Age obtained (If unknown please write “unknown”):
If obtained as a puppy, how was the puppy raised?
In house
In kennel/garage
Loose outside
Puppy mill
Other
Don’t know
N/A
If obtained as a puppy, how did you select that particular puppy from the litter?
Breeder selected
No choice
Most outgoing
Most timid
Biggest
Smallest
Looks
Other
N/A
If previously owned, for what primary purpose was the dog kept?
Adult’s Pet
Family Pet
Children’s Pet
Show dog
Breeding
Guard dog
Farm/Outside dog
Obedience
Service/Working Dog
Hunting Dog
Research/Teaching
Other
Don’t Know
N/A
Primary purpose for which the dog was obtained?
Adult’s Pet
Family Pet
Children’s Pet
Show dog
Breeding
Guard dog
Farm/Outside Dog
Obedience
Service/Working Dog
Hunting Dog
Research/Teaching
Other
Don't Know
N/A
What is the average number of hours that the dog is left alone per weekday?
Schedule on weekends
Is consistent
Varies
Where is the dog when left alone?
Crate
Confined in a room
Loose in living area
Basement
Garage
Outside Kennel
Outside Tied
Loose in yard
Other
N/A
Where is the dog at night?
Crate
Confined in a room
Loose in living area
Basement
Garage
Bedroom
On person's bed
Outside
Other
Exercise (Walks)
Less than 1 per week
Several per week
Once per day
Twice per day
3 times per day
More than 3 times per day
Exercise Schedule
Is consistent
Varies during the week
Dog is walked on:
Off leash
Harness
Flat collar
Head halter
Choke chain
Prong collar
Other
Reason walked with that specific tool:
Dog has been trained to go into a crate readily
Yes
No
Dog attended puppy classes prior to 4 months of age
Yes
No
Dog has been trained with a clicker
Yes
No
Dog is a trained service dog
Yes
No
Attended classes over 4 months of age
Yes
No
Dog has been shown in trials
Yes
No
Dog is trained for other work
Yes
No
At what age did puppy obedience classes start (if applicable)?
Type a question
Level of training:
Basic
Average
Advanced
Performance of dog in class/training situation:
Poor
Fair
Good
Excellent
Don't Know
Performance elsewhere:
Poor
Fair
Good
Excellent
Don't Know
Training aids used (select all that apply):
Off leash
Head halter
Choke collar
Prong collar
Flat collar
Harness
Front clip harness
Don't clip harness
E-collar
Don't know
Types of discipline (select all that apply)
None
Response substitution
Verbal reprimand (i.e. telling the dog "no.")
Distracting
Startling (i.e. shaking a can of pennies)
Physical (i.e. tapping hind end)
Corrections (with prong or e-collar, leash correction, pulling on leash)
Time out
Dominance/Alpha Roll
Water Spray
Other
Diet (select all that apply)
Dry
Canned
Table food
Other
Feeding schedule:
Once per day
Twice per day
More than twice per day
Free access
Feeding schedule:
Is regular
Varies
Please list food/treat types (if any):
Are treats contingent on behavior?
Yes
No
How would you generally describe your dog's temperament? (Check all that apply):
Friendly to owner
Friendly to strangers
Aloof to strangers
Aggressive to strangers
Shy of strangers
Happy/outgoing
Quiet/shy
Anxious
Hyperexcitable
Submissive
Fearful
Fear of noises
Don't know
Comments about temperament (if any):
What was the temperament of the dog as a puppy? (Check all that apply):
Friendly to owner
Aloof
Aggressive to owner
Friendly to strangers
Aloof to strangers
Aggressive to strangers
Shy of strangers
Happy/Outgoing
Quiet/Shy
Anxious
Hyperexcitable
Submissive
Fearful
Fear of noises
Don't know
Please list the problematic behaviors and/or behavior concerns in order of importance to you (please cite specific incidents if applicable):
At approximately what age did you first notice the problem(s)?:
If anything, what have you tried so far to treat the problem(s)?:
How do you feel that your relationship is with your dog?:
What is your favorite thing about your dog?:
Submit
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