Initial Behavior History Form

Initial Behavior History Form
PLEASE NOTE: WE MUST RECEIVE THIS FORM AT LEAST 3 BUSINESS DAYS PRIOR TO YOUR APPOINTMENT. WITHOUT IT, WE MAY NEED TO CANCEL YOUR APPOINTMENT AND RESCHEDULE YOU TO ANOTHER DAY.THIS FORM IS IMPERATIVE TO HELP US HELP YOU AND YOUR PET.

Welcome to Animal Care Center of Castle Pines Veterinary Behavioral Service! We understand how stressful behavioral difficulties in our pets can be, and we are here to help. Our doctors have years of experience treating a wide variety of behavioral concerns – you name it, we’ve likely seen it (many times!) We understand how isolating and scary it can feel to have a pet with behavior concerns, but we are happy to let you know there are many options for treatments to help improve the quality of life for both your pet and your family.

WE DO NOT NEED TO SEE THE BEHAVIOR TO BELIEVE OR UNDERSTAND WHAT IS HAPPENING!
We would rather your pet be as relaxed and comfortable as possible as we review the history and treatment plan. Many behavioral diagnoses and assessments are based off verbal history and discussion.

IF A SECTION DOES NOT APPLY TO YOUR PET AT ALL, PLEASE SAY NO TO THE FIRST QUESTION AND SKIP THE REMAINING QUESTIONS IN THAT SECTION.
IF A SECTION DOES APPLY, BUT IS A MILD CONCERN, PLEASE STILL MARK YES AND ANSWER
THE SUBSEQUENT QUESTIONS.
Name

First NameLast Name
Pet's Name

First NameLast Name
General Information about pet and household
Is your pet part of an active court case or are you pursing court ordered training?(Please note: although we can still work with you and your pet with the aim of improving behaviors, we do not offer court ordered services or provide records explicitly for the court. If you need a reference for that type of service, please let us know.)
Pet age at adoption:
Pet weight:
Where did you acquire your pet:
Do you know any information about your pet prior to bringing them into your family:
What does your pet eat (brand of pet food):
Does your pet have food allergies:
Are there any treats your pet especially loves? If yes, please list (and bring along to the initial appointment!):
Who is your pet’s primary care veterinarian (please list hospital/clinic and doctor if you generally see one specific doctor, or list “any” if you see any doctors at the hospital/clinic):
Do you regularly see any other veterinarians (specialists, recent ER visits, etc)? If so, please list below so that we can collect ALL medical records for your pet prior to your visit:
Please list all people (adults and children) who live in the household – names and ages (for children):
Are there any other adults or children who regularly visit or come over, but do not live in the home? If so, please list names and ages (for children):
Are any of the people in your home (or who regularly visit) at high risk due to bites (example: children, elderly, immune compromised, human behavioral disorders, cognitive disorders, etc.)? If so, please list and explain:
Does anyone in your household have a peanut allergy?
Please list all animals that live in your household:
Has there ever been any aggression between your pet and other animals in the household?
Do you have a yard? If yes please describe the fencing, please note if there are neighboring pets, and if there are issues with those neighboring pets (example: barks at neighbor dog or neighbor dog barks at your pet):
Does your pet regularly bark at doors/windows to the point that is an annoyance to you:
Medical History
Please list all chronic medical conditions and any major medical history (example: hospitalized for parvo as a puppy, past bone fracture repairs, recurrent ear infections, etc. PLEASE NOTE: common medical histories of extra importance include any history of pain, any history of common or recurrent gastrointestinal issues, any history of recurrent ear infections or skin infections, and any history of seizures):
How is your pet’s appetite?
How often does your pet vomit:
How often does your pet have loose stool or diarrhea:
CURRENT Medications or Supplements

Please list ALL medications and supplements that your pet is currently and regularly taking– this is not limited to behavior medications or supplements
Medication/Supplement 1
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Medication/Supplement 2
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Medication/Supplement 3
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Medication/Supplement 4
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Medication/Supplement 5
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Are there any other medications or supplements your pet is on, and which you did not have room to list above? If yes, please list:
TRIALED Medications or Supplements

Please list ALL medications and supplements that your pet has been on in the past or that you have trialed– this is not limited to behavior medications or supplements
Medication/Supplement 1
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Medication/Supplement 2
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Medication/Supplement 3
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Medication/Supplement 4
Name of Medication and strength (example: Rimadyl 100mg tablets):
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Medication/Supplement 5
Dose and Frequency administered (example: ½ tablet given twice daily or 1 tablet given 2 hours before veterinary visits):
Approximate date medication was started (example: January 2019):
Does this medication cause any negative side effects? If yes, please list/explain:
Is this medication helpful? If yes please explain (example: yes, this helps with pain or yes, he is slightly calmer at the vet when he gets this medication 2 hours before visits):
On a scale of 1 to 10, with 1 being not at all helpful and 10 being extremely helpful, how helpful is this medication:
Are there any other medications or supplements your pet is on, and which you did not have room to list above?
Behavior GoalsWhat are your goals with our behavior service – please list these goals in order of importance:
General Anxiety Screen
Do you feel your pet is hypervigilant on walks or in new environments?
Do you feel your pet is hypervigilant in your home?
Do you feel your pet is quick to startle?
Does your pet have difficulty adjusting to new locations or environments?
Does your pet react (startle, avoid, bark, growl, etc) at new items, items that have moved, or items that are out of place?
Do you feel your pet is often restless or has difficulty settling or seems not to rest/sleep much during the day?
Do you feel your pet paces often?
Does your pet sleep through the night?
Does your pet sleep soundly?
Is your pet easily startled awake from sleep?
Cognitive Dysfunction Screen:
Is your pet over the age of 8?
Does your pet newly urinate or defecate in the house?
Does your pet ever get stuck in corners?
Does your pet ever seem lost in your home or yard?
In general, does your pet seem more restless (more pacing or wandering) than he or she used to be?
Specifically, does your pet seem more restless or anxious during or around sunset time?
Is your pet newly having trouble sleeping through the night (restless at night, waking repeatedly, vocalizing at night?)
Is your pet newly whining or vocalizing more frequently?
Does your pet seem to no longer respond to previously known cues or instructions?
Does your pet ever approach the wrong side of the door (the hinge side instead of the open side?
Does your pet ever seem to stare off into space or at walls?
Does your pet seem to not recognize previously familiar people or other pets?
People Directed Aggression Screen (please note, there will be another section focusing on aggression at the vet clinic or with handling, such as grooming):

Please note that there will be other sections focusing on aggression towards other dogs/animals and aggression at the vet clinic/handling.
Does your pet ever show aggression (barking growling, snarling, snapping, lunging, biting) towards people (even if mild, please check yes)?
Please describe the aggression that you see:
Is aggression worse towards certain people or classes of people (example: children, veterinary staff, men, a particular person):
How often do you see aggression towards people? (example: daily, weekly, monthly, every few months, whenever we go to the vet)
Do you feel this behavior has gotten worse over time? If yes, please explain (example: I see the aggression much more frequently OR the aggression has become much more intense):
Is the aggression limited to or worse on leash? If yes, please explain:
Is the aggression limited to or worse in your home or neighborhood? If yes, please explain:
Is the aggression limited to or worse in relation to space, items, food, or certain people? If yes, please explain:
Do you feel it is possible that the aggression is related to pain or discomfort? If yes, please explain:
Is the aggression ever redirected (example: when your dog sees another dog, they start to aggress towards you OR when a visitor is over your cat attacks you)? If yes, please explain:
How old was your pet when you first noticed the aggression?
What was the first aggressive event that you can remember??
Please describe and give the approximate date of any major aggressive events?
Has your pet ever bitten a person (this can include an air snap where no contact was made)? If yes, please describe each event and the severity of the bite:
Has anyone ever needed to seek medical care for a bite? (this can include someone who *should have* sought medical care, but did not):
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list:
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray gun, scruffing, alpha roll, other punishment type action:
Has there ever been any legal action, court cases, or bites reported to Animal Care and Control? If yes, please explain:
Is there anything additional you want to add to this section about aggression towards people that was not asked in the questions above?
Animal Directed Aggression Screen:
Does your pet ever show aggression (barking growling, snarling, snapping, lunging, biting) towards animals (even if mild, please check yes)?
Please list what types of animals (example: dogs, cats, rabbits):
Is this aggression ever directed towards other animals in your household?
Please describe the aggression that you see:
Is aggression worse towards certain animals (example: intact male dogs, dogs that bark at my pet, another pet in the household):
How often do you see aggression towards animals? (example: daily, weekly, monthly, every few months, whenever we go to the vet):
Do you feel this behavior has gotten worse over time? If yes, please explain (example: I see the aggression much more frequently OR the aggression has become much more intense:
Is the aggression limited to or worse on leash? If yes, please explain:
Is the aggression limited to or worse in your home or neighborhood? If yes, please explain:
Is the aggression limited to or worse in relation to space, items, food, or certain people? If yes, please explain:
Do you feel it is possible that the aggression is related to pain or discomfort? If yes, please explain:
Is the aggression ever redirected (example: when your dog sees another dog, they start to aggress towards their housemate OR when a visitor is over your cat attacks your other pets or other items in the home)? If yes, please explain:
How old was your pet when you first noticed the aggression?
What was the first aggressive event that you can remember?
Please describe and give the approximate date of any major aggressive events?
Has your pet ever bitten another animal (this can include an air snap where no contact was made)? If yes, please describe each event and the severity of the bite:
Has an animal ever needed to seek medical care for a bite? (this can include an animal that *should have* had medical care, but did not):
Has your pet ever killed another animal (this can include squirrels, rabbits, birds, mice, etc):
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list:
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray gun, scruffing, alpha roll, other punishment type acti
Has there ever been any legal action, court cases, or bites reported to Animal Care and Control? If yes, please explain:
Is there anything additional you want to add to this section about aggression towards other animals that was not asked in the questions above?
Separation Anxiety Screen
Does your pet bark or howl when you leave the house or left home alone? If yes, please describe:
Does your pet pace, pant, or drool when you leave the house or left home alone? If yes, please describe:
Is your pet destructive when you leave the house or left home alone? If yes, please describe:
Does your pet shadow you constantly?
Do you have a pet cam or web cam to watch your pet when home alone?
How often do you notice the distress when you leave the house or left home alone?
Do you feel the distress when you leave the house or left home alone has gotten worse over time? If yes, please explain:
At what age did your first notice distress when you leave the house or left home alone?
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list:
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray gun, scruffing, alpha roll, other punishment type action:
Is there anything additional you want to add to this section about separation anxiety that was not asked in the questions above?
Noise Phobia Screen
Is your pet distressed by thunderstorms (pacing, panting, drooling, restless, startle, bark, howl, destructive, or anything else of concern)? If yes, please describe:
Is your pet distressed by fireworks (pacing, panting, drooling, restless, startle, bark, howl, destructive, or anything else of concern)? If yes, please describ
Is your pet distressed by other noises (pacing, panting, drooling, restless, startle, bark, howl, destructive, or anything else of concern)? If yes, please describe:
How often do you notice the distress to noises?
Do you feel the distress to noises has worsened over time? If yes, please explain:
At what age did you first notice the distress to noises?
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list:
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray gun, scruffing, alpha roll, other punishment type action:
Is there anything additional you want to add to this section about noise phobias that was not asked in the questions above?
Fear or Aggression Related to Veterinary Handling or Other Handling (grooming, etc) Screen:
Does your pet ever show aggression (barking, growling, snarling, snapping, lunging, biting) or avoidance (cowering, hiding, trembling, panting, climbing up on you or doors, walls, furniture in the exam room, or other non-aggressive, but fearful behaviors) related to veterinary care, grooming, or other handling (even if mild, please check yes)?
Please describe the aggression or avoidance/fear behavior that you see:
How often do you see the aggression or avoidance/fear behavior related to veterinary care, grooming, or handling? (example: daily, weekly, monthly, every few months, whenever we go to the vet)
Do you feel this behavior has gotten worse over time? If yes, please explain (example: I see the aggression much more frequently OR the aggression has become much more intense)
How old was your pet when you first noticed the aggression or avoidance/fear behavior related to veterinary care, grooming, or handling?
What was the first aggressive or avoidance/fear behavior related to veterinary care, grooming, or handling event that you can remember?
Please describe and give the approximate date of any major aggressive events related to veterinary care, grooming, or handling?
Has your pet ever bitten a person (this can include an air snap where no contact was made) during veterinary care, grooming, or handling? If yes, please describe each event and the severity of the bite:
Has anyone ever needed to seek medical care for a bite? (this can include someone who *should have* sought medical care, but did not)
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray gun, scruffing, alpha roll, other punishment type actio
Has there ever been any legal action, court cases, or bites reported to Animal Care and Control? If yes, please explain:
Is there anything additional you want to add to this section about aggression during veterinary care, grooming, or handling that was not asked in the questions above?
Pica (ingesting items other than food and treats) Screen:
Does your pet ever ingest non-food items:
Are there specific items they prefer to ingest? If so, please list:
How often does your pet attempt or succeed at ingesting non-food items?
Do you feel attempting to eat or eating non-food items has gotten worse over time? If yes, please explain:
At what age did your first notice your pet attempt or succeed at ingesting non-food items?
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list:
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray gun, scruffing, alpha roll, other punishment type action:
Is there anything additional you want to add to this section about pica that was not asked in the questions above?
Compulsive Behavior Screen (tail chasing, light chasing, shadow chasing, self-destructive behaviors):
Does your pet ever show compulsive behaviors (such as tail chasing or spinning, shadow or light chasing, or self-destructive behaviors?
Please describe the compulsive behaviors you see:
How often to the compulsive behaviors occur (example: multiple times per day, weekly, during certain times of the day):
Do you feel the compulsive behaviors have gotten worse over time? If yes, please explai
At what age did you first notice the compulsive behaviors?
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list:
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray?
Is there anything additional you want to add to this section about compulsive behaviors that was not asked in the questions above?
Fear/Phobias Screen (other than those already asked about above):
Does your pet exhibit significant fear behaviors in relation to other situations other than those asked about in the above questions (situations other than noises, being left alone, going to the vet or groomer, or other handling – for example – garbage truck day, slippery floors, nearly everything!)?
If you answered yes, please explain what the additional triggers are:
If you answered yes, please explain the behaviors you see (example: panting, pacing, drooling, hiding):
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list:
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray gun, scruffing, alpha roll, other punishment type action
Is there anything additional you want to add to this section about fear or phobias that was not asked in the questions above?
Inappropriate Elimination/Urination Screen
Does your pet ever urinate or defecate in inappropriate locations?
Please describe if it is urination, defecation, or both, and during what situations this happens if possible (it is alright to say you are unsure when or why it is happening!):
Has there been any changes in your home (moved recently, new family member or long term visitor, construction in the house or neighboring house, new animals in the home, new furniture – anything new you an think of!)? If yes, please describe:
How often does the inappropriate elimination occur? (example: multiple times per day, weekly, during certain times of the day):
Do you feel the inappropriate elimination has gotten worse over time? If yes, please explain (example: more frequent, more locations):
At what age did you first notice the inappropriate elimination?
What have you tried to treat this problem thus far? (example, medications, training – please list type of training or trainer, eliminating walks, etc.) Please list:
Have you ever used any of the following treatment methods to treat this problem – shock collar, bark collar, citronella collar, hitting/kneeing, yanking on leash or leash corrections, prong collar, yelling, water/spray gun, scruffing, alpha roll, other punishment type action:
Is there anything additional you want to add to this section about inappropriate elimination that was not asked in the questions above?
Other questions:
Has anyone ever recommended euthanasia due to the behavior concerns?
Have you ever considered euthanasia due to the behavior concerns?
Have you ever considered re-homing due to the behavior concerns?
On a scale of 1 to 10, how concerned or distressed are you by your pet’s behavior concerns (1 = barely concerned; I could manage with this for the rest of his or her life, but it would be great if we could see improvement. 10 = very concerned; If I don’t see improvement within weeks to months I will have to consider no longer keeping my pet in my home):
Did we miss anything?
Are there any concerning behaviors that were not mentioned in this form? If so please describe:
Additional Information:If you have any photos or videos that demonstrate behaviors or concerns that you would like to share, please email them to info@animalcarectr.com – If the file is too large, please mark the photo or video and you can show the doctor at your initial appointment!
Should be Empty:

Initial Behavior History Form

General Information about pet and household

Medical History

CURRENT Medications or Supplements

Medication/Supplement 1

Medication/Supplement 2

Medication/Supplement 3

Medication/Supplement 4

Medication/Supplement 5

TRIALED Medications or Supplements

Medication/Supplement 1

Medication/Supplement 2

Medication/Supplement 3

Medication/Supplement 4

Medication/Supplement 5

General Anxiety Screen

Cognitive Dysfunction Screen:

People Directed Aggression Screen (please note, there will be another section focusing on aggression at the vet clinic or with handling, such as grooming):

Animal Directed Aggression Screen:

Separation Anxiety Screen

Noise Phobia Screen

Fear or Aggression Related to Veterinary Handling or Other Handling (grooming, etc) Screen:

Pica (ingesting items other than food and treats) Screen:

Compulsive Behavior Screen (tail chasing, light chasing, shadow chasing, self-destructive behaviors):

Fear/Phobias Screen (other than those already asked about above):

Inappropriate Elimination/Urination Screen

Other questions:

Did we miss anything?

Additional Information:If you have any photos or videos that demonstrate behaviors or concerns that you would like to share, please email them to info@animalcarectr.com – If the file is too large, please mark the photo or video and you can show the doctor at your initial appointment!