Canine Behavioral History Form

Canine Behavioral History Form

Richmond Campus
At which location are you requesting an appointment?*

FAIRFAX, VA CampusRICHMOND, VA Campus
Primary Owner Name (person filling out the form)*

First NameLast Name
Primary Owner preferred pronouns*

She/HerHe/HimThey/ThemOther
Primary Owner Email*
example@example.com
Primary Owner Phone Number*
Please enter a valid phone number.
Co-Owner Name

First NameLast Name
Co-Owner preferred pronouns

She/HerHe/HimThey/ThemOther
Co-Owner Email
example@example.com
Co-owner Phone Number
Please enter a valid phone number.
Address - mailing*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For ease of recognition, please share a photo of your pet for his/her medical record.

We will not share this image outside of the practice without your express written permission.
Cancelof
Canine/patient name:*
Patient date of birth:*
Is date of birth known or estimate?*

KnownEstimate
Breed:*
Color*
Sex:*
Weight (pounds/lbs):*
Age when spay/neuter performed:*
Name and address of primary care veterinary office (please be specific)
How did you acquire this dog?*

BreederRescueFound/strayOther
Date of adoption/purchase:*
Age of dog upon adoption/purchase?*
Age
What was the dog's history prior to acquisition/adoption (if known)?*

0/150
How much interaction did your dog have with people and other animals in the first year of life (if known)?*

0/150
Briefly describe your dog's personality*
Describe the problem(s) that you are currently having with your dog:*

0/300
When did the problem(s) start?*
Date of onset or coincidence with life events
What has been tried to correct the problem(s)?*
Do you suspect any cause?*
Have there been any changes in the household or routine at the time of onset?*
Describe the three most recent incidents:*

0/200
Describe the dog's body postures during these incidents:*
What was your reaction to the incidents?*
What was your dog's response to your reaction?*
If aggression, what was the result to the victim(s)? (mark all that apply)*

PunctureScratchBruiseTearNo injury to the victim(s)OtherNot applicable
How often does this type of incident occur?*

Multiple times per dayDailySeveral times per weekWeeklyMonthlyInfrequently
If house soiling, does the problem occur:

When you are home with the dogWhen you are not home and the dog is home aloneBoth
What has been done to change or correct the problem(s) in the past (even if it hasn't helped)?*

0/80
What has helped the current problem(s), if anything? *
This problem is getting:*

BetterWorseNo changeOther
Are there any other details surrounding the problem that you feel are relevant?

0/80
Is there any legal action (pending or resolved) regarding these incidences?*

No legal actionYes, legal action is pendingLegal action is resolved at the time of consultationUnknown

Human household occupants:*

	Name	Age	Occupation	Relationship to you	Relationship with patient
Yourself
Other
Other
Other
Other
Other

Animal household occupants (other than patient):

	Name	Age	Sex	Breed	Relationship with patient
Other pet
Other pet
Other pet
Other pet
Other pet

Have you previously owned dogs?*

YesNoYes, but only as a child (family dog)
Have you previously owned this breed of dog?*

YesNo
Where is the dog fed?*
Physical location
Where is the dog fed in relation to the other pets?
If applicable
How do you feed your dog?*

Out of a bowlOut of feeder or puzzle toysA combination of the aboveOther
Do you need to be present for your dog to eat?*

YesNo
Is your dog protective of meals/food?*

Yes, only with peopleYes, only with other pets in the houseYes, only with childrenYes, with both pets and peopleNo, they let anyone take their food awayI don't know as I don't test it out
Where does your dog sleep?*
Does your dog wake you up at night?*

YesNo
If so, why?*
How many hours do you think your dog sleeps per 24/ hour day?*
Where can your dog normally be found during the day?*
How does your dog ask to go outside?*
About how many times per day does your dog get to go outside?*
How long does your dog like to be outside?*
If you have a backyard, what type of fencing does it have?*

Not applicable- no backyardBackyard with privacy fencingBackyard with fencing the dog is able to see through (chicken wire, metal bars, etc)Backyard with Invisible fence with associated shock collarBackyard with no fencingOther
Does your dog run the fenceline barking?*

Yes, only when people are outside or pass byYes, only when other dogs are outside or pass byYes, when either people or dogs are outside or pass byNo, my dog does not run the fencelineNot applicable - no backyard
What type of exercise does your dog get on a daily basis? (mark all that apply)*

Multiple walks per dayOne long walk per dayRunTreadmillChase, catch games (ex- frisbee, balls)Time at daycareTime at a dog parkOther
Is there any specific time devoted to training per day?*

YesNo
Is your dog playful?*

YesNo
What type of toys does your dog like?
Where does your dog stay when no one is home?*

In a crate/kennelConfined in a specific area (ex- using baby gates or closed doors)Loose in the homeMy dog is never left home alone without peopleOther
What does your dog do as you prepare to leave the home?*
How long (approximately) is your dog left alone without people each day?*
Do you record/monitor your pet when it is home alone?*

YesNoWe previously recorded departures, but have stopped
Does your dog exhibit any of the following behaviors when left home alone? (check all that apply)*

Urination in the houseDefecation in the housePacing or panting for prolonged periodsVocalization (whining, crying, barking, howling etc)Salivation/drooling excessivelyDestruction of household itemsRefusal to eat when no one is homeNone of the aboveOther
What arrangements are made if you are out of town?*

In-home pet sitter that stays overnightBoardingIn-home pet sitter that visits several times per dayI leave enough food and water out for the duration of our tripNot applicable - I have never left my pet to travel out of townOther
Has your dog ever attending professional training classes?*

Yes, only as a puppyYes, as a puppy and beyondYes, specifically for this behavioral concernNo, I have only trained the dog on my own
Where have you trained (facility) and with which specific trainers (classes or private lessons)?*
How would you rate your dog's ability to learn?*

GreatAveragePoor
To which cues does your dog respond with reliability?*

ComeSitDownTouchStayWatch me/focusNone of the aboveOther
Does your dog pull on leash?*

YesNoDepends
How do you correct your dog if he/she misbehaves?*
What types of training aides do you CURRENTLY use? (check all that apply)*

TreatsHead halterBody harnessChoke chainProng collarElectronic shock collar (aka "stim" or "vibrate" collars)Penny can or bag of chainsNone of the aboveOther
Which of the following training aides have you used in the PAST? (check all that apply)*

TreatsHead halterBody harnessChoke chainProng collarElectronic shock collar (aka "stim" or "vibrate" collars)Penny can or bag of chainsNone of the aboveOther
What type of home do you live in?*

Apartment/CondoTownhomeSingle family homeOther
How would you describe your home?*

QuietLively
Aggression

Aggression can include any of the following: barking, snarling, lunging, muzzle punching, snapping (no contact), nipping, biting.

Does your dog show aggression in any of the following circumstances? (mark all applicable circumstances/recipients)

	Primary Owner	Co-owner	Children in household	Other particular person
Handling/Grooming
Petting/Hugging
Disturbed when resting
Disciplining
Taking food away
Taking other objects away

How does your dog respond when the doorbell rings?*
Is your dog quick to approach visitors in the home?*

YesNoDepends on the visitor

What is your dog's response to the following situations?*

	Inside the home	Outside the home
Frequent visitors
Occasional visitors
Unknown men
Unknown women
Unknown children
Unknown dogs (on leash)
Unknown dogs (off leash)
Crowds/busy areas
Trucks/buses/cars

Does your dog show inappropriate mounting or other sexual activity?*

YesNo
Is your dog protective of certain parts of his/her body?*

YesNo
Which parts?*
ex. "head, feet..."
Does your dog lick or chew themselves more than you would expect?*

YesNo
Does your dog lick or chew other things (people or surfaces) more than you would expect?*

YesNo
Please explain.*
Describe the behavior.
What is your dog's response to veterinary handling/intervention? Please check ALL that apply:*

Loves vet visits. No fear, stress, or anxiety of any kind. Happy as a clam.Mildly distressed (panting, whining, etc.), but allows veterinary staff to examine, restrain, and perform treatments with no signs of aggression and will still take treats.Moderately distressed (attempts to hide, vocalizations, trembling, will not accept treats, etc.), but no signs of aggression.Severely distressed (shut down and overwhelmed; may urinate, defecate, or express anal glands; may vomit or get diarrhea after visits), but allows veterinary staff to examine, restrain, and perform treatments with no signs of aggression.Has displayed aggression toward vet staff in the form of staring, barking, lunging, growling, or air snapping.Has displayed aggression toward vet staff in the form of nipping or biting.Must wear a muzzle at the veterinary clinic.According to vet staff, aggression subsides when I am NOT present (ex. patient has been taken into a treatment area in the back).Has been administered or prescribed medication to alleviate fear, anxiety, and stress during veterinary procedures.Has been fully sedated by vet staff in order to safely complete a blood draw, vaccination, nail trim, or other routine procedures such as examination.Veterinary handling/intervention is one of my primary reasons for seeking treatment.
Does your dog display reactions to thunderstorms?*

YesNo
Please explain the reaction.*
Describe the behavior.
Does your dog display reactions to fireworks?*

YesNo
Please explain the reaction.*
Describe the behavior.
Does your dog startle at loud noises that are not thunder, fireworks, or gunshots? (ex. if you drop a book, if you clang a pot or pan)*

YesNo
Please explain the reaction.*
Describe the behavior.
Does your dog display any of the following reactions when traveling in the car? (mark all that apply)*

Attempts to avoid loading into the carHypersalivationHyperventilationInability to settleVocalizationsVomitingTremblingHidingNone of the aboveOther
Does your dog ever do any of the following? (mark all that apply)*

Chase, pounce or attack lights or shadowsChase their tailSnap at the air when nothing is presentSuckle on themselves or blanketsNone of the above
Are there any other behaviors you find objectionable?
What are the primary owner's thoughts about the current problem(s)?*
What are the co-owner's thoughts about the current problem(s)?
What are other family members thoughts about the current problem(s)?
What are your expectations for change?*
What are your goals for treatment?*
Under what circumstances would you rehome this dog?*
Under what circumstances would you place this dog up for adoption or relinquish to a rescue?*
Under what circumstances would you consider behavioral euthanasia for this dog?*
What is one thing you LOVE about your dog?*
Should be Empty: