Dog behaviour form
www.behaviour.services
DETAILS OF YOUR HOUSEHOLD
Your Name (person completing the form)
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Address
Street Address
Street Address Line 2
City
Post Code
Please list details of human members of your home (please include yourself)
Rows
Name
Age
Relationship with pet
Family member
1
Family member
2
Family member 3
Family member 4
Family member 5
Family member 6
Family member 7
Complete the details for the pet in question. If the problem relates to behaviours between multiple pets then please choose one pet here and complete details for the others in the table below.
*
Rows
Name
Age
Breed
Gender
Neuter status
Pet details
For how long have you owned your dog?
Please list details of the other animal members of your home (furry or not!)
Rows
Name
Species
Age
Gender
Neuter status
Relationship with pet?
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5
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MEDICAL (AND MEDICATIONS)
Medical problems
Rows
Please provide a list/details here
Ongoing medical problems
Historic medical problems
Do you have any concerns regarding your dogs health?
Medications
Rows
Please provide a list/details here
Medications (including behaviour) your dog is currently on
Supplements e.g. herbal your dog is currently on
Behaviour medications that have been tried in the past
Have you ever noticed the following behaviours with your dog
Rows
Not noticed / unsure
Never occurs
Rarely occurs
Occasionally occurs
Frequently occurs
Details you wish to provide
Eating of non-food items e.g. stone, grass, faeces.
Vomiting
Loose stools/faeces (unable to pick up without leaving a trace on the ground)
More than 2 stools/faeces passed a day
Excessive gassiness
Gurgly tummy noises
Burping
Licking the air
Licking surfaces such as beds, floors, walls (when no food is present)
Excessive licking of own body parts
Hesitations at getting on or off a higher surface such as the car or a sofa
Dislike of car travel (particularly when accelerating, decelerating or cornering)
Dislike of specific parts of their body being handled
Shuffling around whilst defecating (can't stay still)
Defecating a little, getting up to move, defecating again..
A slightly lop sided position whilst urinating (if female)
Urinating whilst standing on all 4 legs (if male)
Bunny hopping (back legs move like a bunny whilst trotting)
Skipping seen (quick flick of a leg)
Stretching of front legs but not following through with a stretch of back legs
Stretching of back legs with no stretching of front legs prior to this
Any stiffness when rising from a period of rest
Struggling to remain settled / asleep for longer stretches (up to 1 hour)
Appearing moody / irritable at times
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DETAILS OF THE PROBLEM BEHAVIOURS
Please answer these questions for each problem in turn
Problem behaviour one
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What is the problem behaviour? (Examples will be asked for later)
*
How important is this problem to you?
Low importance
Medium importance
High importance
What is the approximate date the problem started?
Please list all of the situation(s) the problem occurs in (please describe how these may have changed over time if applicable)
How often does the problem occur? (please feel free to state per day / per week / per month depending on frequency)
Please describe the details of the first incidence of the problem you can recall
Please describe the details of the most recent incident you can recall
Please describe the details of the most memorable incident you can recall
What has been done to correct the problem? Please note whether each intervention has made the problem better, worse, has had no effect or if there has been a variable effect.
Rows
The intervention you tried
Approximate dates
Do you feel this made the problem better, worse, has had no effect or if there has been a variable effect?
Intervention 1
Better
Worse
No Effect
Variable Effect
Intervention 2
Better
Worse
No Effect
Variable Effect
Intervention 3
Better
Worse
No Effect
Variable Effect
Intervention 4
Better
Worse
No Effect
Variable Effect
Intervention 5
Better
Worse
No Effect
Variable Effect
Intervention 6
Better
Worse
No Effect
Variable Effect
Overall, is the problem getting better, not changing, getting worse or is variable?
Do you suspect a cause?
Is there anything else you think is relevant to mention now? We will discuss all details within the consult.
Problem behaviour two
Â
What is the problem behaviour? (Examples will be asked for later)
How important is this problem to you?
Low importance
Medium importance
High importance
What is the approximate date the problem started?
Please list all of the situation(s) the problem occurs in (please describe how these may have changed over time if applicable)
How often does the problem occur? (please feel free to state per day / per week / per month depending on frequency)
Please describe the details of the first incidence of the problem you can recall
Please describe the details of the most recent incident you can recall
Please describe the details of the most memorable incident you can recall
What has been done to correct the problem? Please note whether each intervention has made the problem better, worse, has had no effect or if there has been a variable effect.
Rows
The intervention you tried
Approximate dates
Do you feel this made the problem better, worse, has had no effect or if there has been a variable effect?
Intervention 1
Better
Worse
No Effect
Variable Effect
Intervention 2
Better
Worse
No Effect
Variable Effect
Intervention 3
Better
Worse
No Effect
Variable Effect
Intervention 4
Better
Worse
No Effect
Variable Effect
Intervention 5
Better
Worse
No Effect
Variable Effect
Intervention 6
Better
Worse
No Effect
Variable Effect
Overall, is the problem getting better, not changing, getting worse or is variable?
Do you suspect a cause?
Is there anything else you think is relevant to mention now? We will discuss all details within the consult.
Problem behaviour three
Â
What is the problem behaviour? (Examples will be asked for later)
How important is this problem to you?
Low importance
Medium importance
High importance
What is the approximate date the problem started?
Please list all of the situation(s) the problem occurs in (please describe how these may have changed over time if applicable)
How often does the problem occur? (please feel free to state per day / per week / per month depending on frequency)
Please describe the details of the first incidence of the problem you can recall
Please describe the details of the most recent incident you can recall
Please describe the details of the most memorable incident you can recall
What has been done to correct the problem? Please note whether each intervention has made the problem better, worse, has had no effect or if there has been a variable effect.
Rows
The intervention you tried
Approximate dates
Do you feel this made the problem better, worse, has had no effect or if there has been a variable effect?
Intervention 1
Better
Worse
No Effect
Variable Effect
Intervention 2
Better
Worse
No Effect
Variable Effect
Intervention 3
Better
Worse
No Effect
Variable Effect
Intervention 4
Better
Worse
No Effect
Variable Effect
Intervention 5
Better
Worse
No Effect
Variable Effect
Intervention 6
Better
Worse
No Effect
Variable Effect
Overall, is the problem getting better, not changing, getting worse or is variable?
Do you suspect a cause?
Is there anything else you think is relevant to mention now? We will discuss all details within the consult.
Problem behaviour four
Â
What is the problem behaviour? (Examples will be asked for later)
How important is this problem to you?
Low importance
Medium importance
High importance
What is the approximate date the problem started?
Please list all of the situation(s) the problem occurs in (please describe how these may have changed over time if applicable)
How often does the problem occur? (please feel free to state per day / per week / per month depending on frequency)
Please describe the details of the first incidence of the problem you can recall
Please describe the details of the most recent incident you can recall
Please describe the details of the most memorable incident you can recall
What has been done to correct the problem? Please note whether each intervention has made the problem better, worse, has had no effect or if there has been a variable effect.
Rows
The intervention you tried
Approximate dates
Do you feel this made the problem better, worse, has had no effect or if there has been a variable effect?
Intervention 1
Better
Worse
No Effect
Variable Effect
Intervention 2
Better
Worse
No Effect
Variable Effect
Intervention 3
Better
Worse
No Effect
Variable Effect
Intervention 4
Better
Worse
No Effect
Variable Effect
Intervention 5
Better
Worse
No Effect
Variable Effect
Intervention 6
Better
Worse
No Effect
Variable Effect
Overall, is the problem getting better, not changing, getting worse or is variable?
Do you suspect a cause?
Is there anything else you think is relevant to mention now? We will discuss all details within the consult.
Problem behaviour five
Â
What is the problem behaviour? (Examples will be asked for later)
How important is this problem to you?
Low importance
Medium importance
High importance
What is the approximate date the problem started?
Please list all of the situation(s) the problem occurs in (please describe how these may have changed over time if applicable)
How often does the problem occur? (please feel free to state per day / per week / per month depending on frequency)
Please describe the details of the first incidence of the problem you can recall
Please describe the details of the most recent incident you can recall
Please describe the details of the most memorable incident you can recall
What has been done to correct the problem? Please note whether each intervention has made the problem better, worse, has had no effect or if there has been a variable effect.
Rows
The intervention you tried
Approximate dates
Do you feel this made the problem better, worse, has had no effect or if there has been a variable effect?
Intervention 1
Better
Worse
No Effect
Variable Effect
Intervention 2
Better
Worse
No Effect
Variable Effect
Intervention 3
Better
Worse
No Effect
Variable Effect
Intervention 4
Better
Worse
No Effect
Variable Effect
Intervention 5
Better
Worse
No Effect
Variable Effect
Intervention 6
Better
Worse
No Effect
Variable Effect
Overall, is the problem getting better, not changing, getting worse or is variable?
Do you suspect a cause?
Is there anything else you think is relevant to mention now? We will discuss all details within the consult.
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Aggressive behaviours
Do any of the problem behaviours you described above involve a form of aggressive behaviour? These can include muscular tension with a fixed stare, baring teeth, growling, snarling, lunging, air snapping, bites (contact made)
*
Yes
No
Out of the contexts below, please describe which aggressive behaviours have occurred.
Rows
No aggressive behaviours in this context
Situation does not occur
Muscular tension with a fixed stare
Baring teeth
Growling
Snarling (vocalisation whilst showing teeth)
Lunging
Air Snapping
Bite: contact made but skin not broken
Bite: contact made and skin broken.
Did not need medical attention.
Bite: contact made and skin broken.
Needed medical attention.
Being handled / groomed by you
Taking food away
Taking items away
Disturbed when resting
If disciplined
Being fussed (petted / hugged)
Being handled by a vet or groomer
Visitors - known to dog
Visitors - unknown to dog
On walks - to other dogs
On walks - to people
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HOME ENVIRONMENT
What type of home layout do you have?
What degree of access does your dog have to the home?
What is a typical 24 hours in the life of your pet. Please indicate times when your pet's routine may change.
If any of the problem behaviours occur in the home then please provide a floor plan of your home. Indicate where exit/entrances are and where resources (beds, water bowls, food, toys and other resources are)
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Training and Walks
If your pet goes for walks then note down approximately how often these occur and the duration on and off lead.
Rows
Number of walks a day
Number of walks a week (if not walked daily)
Approximate duration of each walk
Approximate time off lead
If your dog does not go for walks please tick this box
Walks
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Essential changes needed
What are the essential changes you need to continue living with your dog?
Under what circumstances would you consider euthanasia?
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