VVBM Behavior Questionnaire For Dogs

Behavior Questionnaire For Dogs
PATIENT INFO
Pet's name*
Breed*
Color*
Age*
Date of birth*
Sex*
Neutered/Spayed (Y/N & Clarify which one)*
OWNER INFO
Last name*
First name*
Street address*
City, State, ZIP*
Preferred phone*
Secondary phone
Email*
example@example.com
HOME ENVIRONMENT

Please list the people, including yourself, living in your household*

	Name	Age	Pronouns	Relationship (i.e. self, spouse)	Occupation (Optional but sometimes helpful)	Average # of hours away from home per day
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6

Please list all the animals in the household in the sequence they were obtained*

	Name	Species	Breed	Sex	Neutered?	Age obtained	Age now
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5

Household Pet #1: Quality of relationship with patient we are seeing*
Household Pet #2: Quality of relationship with patient we are seeing
Household Pet #3: Quality of relationship with patient we are seeing
Household Pet #4: Quality of relationship with patient we are seeing
Household Pet #5: Quality of relationship with patient we are seeing
BEHAVIOR

Please fill out the sections below in regard to your dog's primary behavior problems you would like addressed.
Problem #1*

Please include dates and details of recent incidents0/150
Age at which problem #1 began *
Problem #2

Please include dates and details of recent incidents 0/150
Age at which problem #2 began
Problem #3

Please include dates and details of recent incidents0/150
Age at which problem #3 began
BACKGROUND INFORMATION
Where did you get your dog?*
Has this dog had other owners?*

YesNo
If yes, why was the dog given up by the previous owners?
Why did you acquire this dog?*
Do you know if the parents or littermates engaged in similar behaviors?*

Yes they did/doNo they don't/haven'tI don't know
Briefly describe your dog's behavior as a puppy (e.g. activity level, response to instructions)
INTERACTIONS WITH OTHER ANIMALS
1. What is your dog's relationship with the other animals in your household?*
2. What is your dog's response to unfamiliar dogs?*
3. Does your dog interact with other dogs, besides those in your household, on a regular basis? If so, when and where?*
4. What is your dog's response to cats or other small animals outside your household?
INTERACTIONS WITH HOUSEHOLD PEOPLE

Please tell us if there is any aggression in the following circumstances to any members of your household. This may include growling, showing teeth, lunging, nipping, snapping, or biting. Please fill in the chart with "Y" if there has been any aggression to any family member in each circumstance, "N" for no aggression, and N/A if the circumstance does not apply.

	Female Adults	Male Adults	Children	Specific Person
Petting or reaching for dog
Hugging or kissing dog
Bathing, grooming, or toweling dog
Disturbing dog when resting
Pushing/calling dog off furniture
Giving verbal or physical corrections
Approach/interact when dog is eating or has a high value item
Putting on leash or collar
Lifting dog

INTERACTIONS WITH HOUSEHOLD PEOPLE contd.

Regarding the table above, please provide brief details for each situation (if applicable).
Petting or reaching for dog
40 character limit
Hugging or kissing dog
40 character limit
Bathing, grooming, or toweling dog
40 character limit
Disturbing dog when resting
40 character limit
Pushing or calling dog off furniture
40 character limit
Giving verbal or physical corrections
40 character limit
Approach/interact when dog is eating or has a high value item
40 character limit
Putting on leash or collar
40 character limit
Lifting dog
40 character limit
INTERACTIONS WITH NON-HOUSEHOLD PEOPLE

Please tell us if there is any aggression in the following circumstances to any person who is not a member of your household. This may include growling, showing teeth, lunging, nipping, snapping, or biting. Please fill in the chart with "Y" if there has been any aggression in each circumstance, "N" for no aggression, and "N/A" if the circumstance does not apply.*

	Female adults	Male adults	Children	Specific person
Petting or reaching towards dog
Entering your house or yard
Enter/exit any room in your house
Passing when dog is on walks
Passing when dog is in the car

INTERACTIONS WITH NON-HOUSEHOLD PEOPLE contd.

Regarding the table above, please provide brief details for each situation (if applicable).
Petting or reaching towards dog
Entering your house or yard
40 character limit
Enter/Exit any room in your home
40 character limit
Passing when patient is on walks
40 character limit
Passing when dog is in the car
40 character limit
What is your dog's response to frequent visitors?*

0/30
What is your dog's response to occasional visitors?*

0/30
What is your dog's response to rare visitors?*

0/30
What is your dog's response to repair/delivery persons?*

0/30
FEARS AND ANXIETIES

Please complete the table below. Please check all that apply.

	Defecate	Urinate	Salivate	Tremble	Tucks Tail	Hide	Escape	Destroy	Vocalize
Dog is home alone
Dog is home alone with another pet
Dog is home with family but separated from family members
Dog is home alone confined to a crate
Dog is at veterinary office
Dog is at groomer's
Fireworks
Thunderstorms
Loud noises
Car rides

Please list any specific stimuli (i.e., men, umbrellas, traffic noises) your dog seems to be afraid of*

0/50
TREATMENT

This questionnaire is designed to help us evaluate any role previous treatment may play in either your dog's problems or in their resolution. Please check the items that were recommended and/or attempted. If your dog responded aggressively or with fear as a result of the use of any of these methods, please indicate this response in the "outcome" column. If applicable, please BRIEFLY describe outcome.*

	Tried (Y/N)	Outcome (Aggression, fear, improved behavior, worsened behavior, etc.)
Stare at or "stare down"
Grab by jowls/scruff +/- shake
Shake or throw a can
Step on leash or choke collar and force down
"Time out" (if done, specify where, when, and for how long)
Metal choke or pronged collar
Water pistol/spray
Halti or Gentle Leader head collar
No-pull Harness (i.e. Easy Walk)
Bark or remote-activated shock collar
Invisible/electric fence (inside or out)
Citronella spray collar
Forced exposure to frightening stimuli
Knee dog in chest/belly for jumping
Hit or kick dog
Growl at dog
"String up" or hang by leash or collar
Rub dog's nose/face into urine, feces or destruction
Tie or tether on short lead hooked to wall or floor
Yell "no" at dog
"Alpha roll" (hold on back, put down on back)
"Dominance down" (hold on side, legs extended, head flat)
Use of food or puzzle toys (Kongs, etc)
Praise for good behavior
Food rewards for good behavior
Tether/tie out on a line in yard
Use of muzzle at home or on walks
Clicker training
Avoidance of stimuli that trigger fear or aggression
Feed meals by hand
Remove food bowl while eating
Pheromones (DAP, Comfort Zone)
Anything else that was tried?

ENVIRONMENT
1. What type of area do you live in (Urban, suburban, etc.)?*
2. What type of home do you live in (studio, apartment, house)?*
3. Do you have a yard?*

YesNo
Do you have a fence?*

YesNo
If so, what type of fence do you have and how tall?
5. Has your household changed since acquiring your dog?*

YesNo
If so, how?
DAILY SCHEDULE
1. How many times is your dog walked on a leash per day (select one)?*

01234>5
2. What is the average length of each leash walk (please do not include yard time)?*
3. How many times is your dog let out in the yard each day (select one)?*

01234>5
How many hours per day does your dog spend OUTDOORS unsupervised?*
Does your dog have access to the outside through a dog door?*

YesNo
4. Where is your dog when home alone? (i.e. confined to a room or crate, loose in the house, outdoors, etc.)*
5. Do you limit your dog's access to any part of the house when you are home? If so, please explain:*
6. Where is your dog when you have guests? Please indicate whether this is by choice, or whether you put him/her there.*
11. Where does your dog sleep at night?*
DIET AND FEEDING
1. What do you feed your dog? (Please be specific, i.e. brand name, canned vs. dry)*
2. How many meals is your dog fed each day?*
3. Where is your dog's food bowl?*
4. Please describe the meal routine including if other animals eat at the same time, describe the arrangement (e.g. same room, separate rooms, etc.)*
5. Does your dog finish each meal?*

YesNo
6. Does someone have to be present for your dog to eat?*

YesNo
7. Does your dog have any food allergies or diet restrictions?*

YesNo
If so, please describe
MEDICAL HISTORY
1. At what age was your dog neutered/spayed (if applicable)?*
Reason
2. If your dog is not neutered has he/she ever been bred?*

YesNoUnsure
3. Are you planning to breed your dog?*

YesNoUnsure
4. Is your pet currently receiving heartworm and flea/tick prevention?*

YesNo
If so, please list the type
5. Do you ever use the following medications/treatments for your dog? (only select if applicable)

Tramadol (pain medication)Preventic collar
6. Is your pet on any medications at this time? If so, please specify*
MEDICAL PROBLEMS

Please list any previously diagnosed medical problems and how they were treated

	Date	Diagnosis	Treatment (including medications and dosage)	Outcome
Medial Problem #1
Medical Problem #2
Medical Problem #3
Medical Problem #4
Medical Problem #5

Please list any BEHAVIORAL medications/supplements you have administered to your pet

	Date	Treatment	Outcome
Medication/Supplement #1
Medication/Supplement #2
Medication/Supplement #3

TRAINING
Has your dog ever attended a training class or had a trainer come to your home?*

YesNo
If yes, please give details (when, where, age of dog, who trained dog)
What method of training was used (i.e. clicker training, leash corrections, special collars, etc.)
Name of trainer?
How did your dog perform in training class?
Have you consulted any other behavior specialists prior to your appointment with us?*

YesNo
If yes, who?
MISCELLANEOUS
1. Does your dog ever mount people, dogs or objects?*

YesNo
If so, who/what and how often?
2. Does your dog ever lick people, himself, or inanimate objects excessively?*

YesNo
If so, who/what and how often?
3. Is your dog sensitive about having certain body parts touched or handled (especially ears and feet)? If yes, which parts?*
Do you have any issues with your dog urinating or defecating inside your home?*

YesNo
If yes, please elaborate
5. Has the frequency or intensity of the behavior changed since the problem started?*

YesNo
If yes, how and when?
6. How do you react when your dog shows problem behaviors?*
7. How does your pet respond to your reaction?*
BITE HISTORY
1. If your dog has ever bitten anyone, please list the total number of bites and description of each incident*
2. Please list the number of bites that broke skin
3. Please list the number of bites reported to public health authorities, and to whom: (i.e. local authorities, hospital, humane society, etc.)
4. Was there legal action taken against you as a result of the bite(s)?

YesNo
5. Have you considered finding another home for this dog?*

YesNo
6. Have you considered euthanasia (putting your dog to sleep)?*

YesNo
GOALS
What are your goals for your behavior appointment?*

0/75
Should be Empty:

Behavior Questionnaire For Dogs

PATIENT INFO

OWNER INFO

HOME ENVIRONMENT

BEHAVIOR

BACKGROUND INFORMATION

INTERACTIONS WITH OTHER ANIMALS

INTERACTIONS WITH HOUSEHOLD PEOPLE

INTERACTIONS WITH NON-HOUSEHOLD PEOPLE

FEARS AND ANXIETIES

TREATMENT

ENVIRONMENT

DAILY SCHEDULE

DIET AND FEEDING

MEDICAL HISTORY

MEDICAL PROBLEMS

TRAINING

MISCELLANEOUS

BITE HISTORY

GOALS