Dog Behaviour History Form

Dog Behaviour History Form
The following form takes some details about you and your dog, and the problem you are seeking help for. Please complete it in as much detail as possible. Please note that Companion Minds: Animal Behaviour & Training, are not a veterinary behaviour service. In all cases where further medical tests or medication is required these will be arranged and charged through the referring veterinary surgeon. Please refer to our website (www.companion-minds.com) for further information & contact details.

We encourage all members of the household to discuss this form but it should be completed by the person who spends most time with the dog. If there is disagreement between any individuals then it is useful to note this under the respective question.

If you are seeking support for more than one dog for their behaviour, please complete a form for each dog.
Owner Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Contact Number
Mobile preferred
What previous experience do you have with dogs?
Briefly explain the reason for obtaining the dog for whom you would like help with now:
Briefly explain your ideal dog here
Some information about your dog you'd like support with
Name
Sex
Breed/Type
For cross breeds please state individual breeds where known, or predominant breed.
Date of Birth/Age
Age when obtained
Vaccination status
Please describe the nature of the problem you'd like support with. If there are multiple presenting issues, please bullet point these. *
e.g. 'barking and lunging towards other dogs' 'howls when left alone' 'resource guarding of toys'
Is your dog on any medication or supplements (if yes please state name and dosage)
Known medical history *
About your home
Type of home (flat/semi detached/detached)
Degree of access dog has in the house
e.g. all of downstairs but not upstairs

Please list all family members who live at home here:*

Rows	Name	Age	Relationship with dog
Person 1
Person 2
Peson 3
Person 4
Person 5

Any other persons in the household:

Please list other household pets here:

Rows	Name	Species	Age	Sex/Neutered?
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5

Any other pets in household
Your dog's early development:
Where did you get your dog from?*
e.g. breeder, rescue
Details of early life if known: litter size, where the puppies were raised, incidents of rehoming etc. *
How as your dog housetrained? How old were they housetrained by?
How did you treat mishaps at this time?
Have you ever attended training classes with this dog?
Please give details- when, where, age of dog, what was covered, methods used
How did your dog do in class?

Very wellAveragePoorWas asked to leaveNot sure
Obedience cues known

SitStayDownPawOther
Intelligence: do you think your dog is...

GoodAveragePoor
How do you react to your dog if they 'misbehave' or do something you'd rather they didn't? *
Your dog's personality
Describe your dog's personality*
e.g. excitable, affectionate, independent, nervous
When faced with a new situation how is your dog likely to react if on the lead? *
Does the behaviour change if on a lead as opposed to being free?*
Does your dog have any known fears/dislikes (other than the issue you'd like help with if this is a fear)*
e.g. hoover, getting in the car, being groomed

Reaction when outside the house:*

Rows	Response
Unfamiliar Male person
Unfamiliar Female person
Unfamiliar Children
Unfamiliar dogs
Known dogs
cats/rabbits/birds/deer/livestock
Busy places (e.g. lots of people/dogs)

Please list below your dog's five favourite things to eat:*
Please list below the five toys/items/activities your dog is most fond of?*
Has your dog ever bitten or attacked anyone? *
Please provide as much detail as possible- what was happening before and after the incident. How often does this occur?
Describe a typical 24 hours for your dog*
Does your dog ever wake you at night? If yes, how often and why/
On average, please estimate how many hours your dog sleeps in a 24 hour period
Do you walk your dog? If so, how often and for how long? Is this on or off lead? Please state what walking equipment you use (e.g. harness, head collar, slip lead, choke chain etc). *
Can your dog be off lead in the garden? Do they use the garden to exercise in?
Typically how long is your dog left alone for without people on any given day?
Who initiates play times, you or the dog?
What is your dog's favourite thing to do?
What is your dog's least favourite thing to do?
be bathed, travel in the car

Dietary details

Rows	Details
Feed type
Amount
Time of day
Fed by whom?
Is your dog protective of their food?
List any supplements, treats, or titbits your dog receives?
How much does your dog drink each day?

Social Behaviour
Has your dog ever shown aggressive behaviour (growling/snarling/snapping/biting) to any members of the household? If yes, please give details*
Does your dog treat all members of the household the same? Please give details of any differences

How does your dog respond to the following visitors to the house?*

Rows	Description of behaviour
Familiar people
Unfamiliar male
Unfamiliar female
Unfamiliar children
Unfamiliar dogs
Known dogs/other animals?
Any particular group of people that your dog responds to differently/in a specific way?

Is your pet ever protective over parts of their body- if yes please state where and what the response is (e.g. ears/tail/feet?)*

Is there any sort of aggressive behaviour in the following circumstances

Rows	Adult females	Adult Males	Children	Specific Individual
When handling/grooming
Disturbed when resting
If told off
When walking on lead towards other people
If trying to remove food/chews from the dog
When fussing or hugging
If trying to remove other objects from them

Does your dog show aggressive behaviour when examined by the vet

YesNo
If yes, please provide details
Does your dog ever show any mounting/humping behaviour or any other sexual activity?

YesNo
If yes, please provide details
The Current Problem(s)
When did each problem you'd like help for start?*
How long has it been present for?*
How old was the dog when it began?*
When does the issue occur?*
With whom?*
How frequently does the problem occur (times per day/week/month/year?)*

Please describe the first incidence of the behaviour that you can recall, the most recent incident and another one you remember:*

Rows	Provide as much detail as possible
First incident
Most recent incident
Another incident

What has been done to try to improve the behaviour so far? Please indicate whether each measure has helped, made no difference, or made things worse?*
Is the problem getting...

BetterWorseNo change
Why do you think your dog is behaving in this way? *
Any other details of the main behaviour issue?
What are the feelings of each family member about the dog's present behaviour?
What are you hoping to achieve?*
What are the essential changes you need to be able to continue to live with your dog?
Under what circumstances would you consider rehoming your dog?
Under what circumstances would you consider euthanasia
Please give any other information you think may be relevant to the case?
Please attach photos of any injuries caused if you have them, or videos of the problematic behaviour. Please do not deliberately cause the problematic behaviour to occur in order to capture footage, but any footage you do have available may be useful.

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In cases of aggressive behaviour please answer the following:

Rows	Details
Describe the incident and setting in which the aggressive behaviour occurred? (where was the dog, where was everyone else, what was everyone doing before the incident, what did your dog do and what did he do before and after the event?)
Are you aware of a trigger for the behaviour?
Were you aware of any warning signs before the incident
What was your immediate reaction?
What was the reaction of the person the dog showed aggressive behaviour towards?
How did your dog respond to this reaction?
If there was a bite wound, where was it located, how deep was the wound etc?

Thank you for completing this form. Once we have received this form AND the veterinary referral form, we will contact you to arrange your consultation.
Which level of follow up would you like to opt for? Both packages include home visit consultation, report, veterinary liaison, and email/whatsapp communication between appointments. Please note there is an additional charge for in person visits for clients beyond 15 miles of DN20.*

£475 Silver package: 3 hours of in person/zoom follow up to use within 3 months of consultation£575 Gold package: 6 hours of in person/zoom follow up to use within 6 months of consultation
Should be Empty:

Dog Behaviour History Form

Some information about your dog you'd like support with

About your home

Your dog's early development:

Your dog's personality

Social Behaviour

The Current Problem(s)

Thank you for completing this form. Once we have received this form AND the veterinary referral form, we will contact you to arrange your consultation.