Canine Behavior Recheck Form

Canine Behavior Recheck Form
Welcome to our Canine Behavior Recheck Appointment Form.

Important:

It is important to know that this form will require a lot of information and often can take between 15-20 minutes to complete. The information you provide is incredibly important to our team and we appreciate all efforts to fill this form out to the best of your ability.

After you fill this form out in its entirety, be sure to click Submit at the end of the form. You will then be directed to a confirmation page and a copy of your responses will be sent to the email you provide.

If you have submitted your form and have not heard back from our team within 72 hours OR you did not receive an email confirmation of your form submission, check your spam folder then please reach out to us directly at behavior@hickoryvet.com.
Dog Recheck History
Patient's Name *
Breed*
Age*
Gender*
Owner's Name*
If you have moved since your last visit please provide your new address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Secondary Phone Number
Who is your primary veterinarian? *
What is your Email Address? *
What is the primary problem being rechecked? *
What are your goals for this recheck consultation? (Please be specific) *
Behavior Medications Your Dog Is Currently Taking
How many medications is your dog taking?

123More than 3
Medication 1 - Name of medication and strength
Medication 1 - What is the dosage?
Medication 1 - Any Side Effects
Medication 1 How Severe are the side effects ?
Response to Medication 1

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Medication 2 - Name of medication and strength
Medication 2 - What is the dosage?
Medication 2 - Any Side Effects
Medication 2 How Severe are the side effects ?
Response to Medication 2

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Medication 3 - Name of medication and strength
Medication 3 - What is the dosage?
Medication 3 - Any Side Effects
Medication 3 How Severe are the side effects ?
Response to Medication 3

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
If your pet is taking more than three medications, please list the remaining medications here with relevant information.
Pre-Existing Behavioral Problems
Describe the primary problem*
Primary Problem - Improvement of Intensity*

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Primary Problem - Improvement of Frequency*

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Describe the secondary problem
Secondary Problem - Improvement of Intensity

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Secondary Problem - Improvement of Frequency

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Describe any additional problem
Additional problem - Improvement of Intensity

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Additional Problem - Improvement of Frequency

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Describe any additional problem
Additional Problem - Improvement of Intensity

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
Additional Problem - Improvement of Frequency

WorseSame<25% Better25-50% Better50-75% Better75-90+% Better
If your pet has developed any new behaviors, either desirable or undesirable, please describe them*
Please give us a detailed description of recent representative events of each current problem. Please include the location, dog’s body postures, any people present, any triggers, your reaction, and the final outcome.*
Have there been any changes in your house since your last appointment?*

YesNo
If so, what has changed?

Family moved to a new homeFamily schedule changedPet AddedDeath/Relinquishment of other petDeath of a household memberDeparture of a household memberArrival of a new household memberMarriageDivorceBirth/Adoption of a childOther
If you checked "other" please describe
Does your pet respond differently to one family member then the others? Has this changed since your last visit? If so please describe: *
Current Management
How are you handling specific situations with respect to the problems listed above, e.g., confining your pet when visitors arrive, using window films, getting a pet sitter when you go to work? How does your pet react? Do you feel this is working?*
Please indicate below what recommendations you have implemented what what was the outcome:
Recommendation*
Outcome*
Recommendation*
Outcome*
Recommendation*
Outcome*
Please indicate below what specific exercises have you worked on, and how have you progressed with them
Exercise #1*
Attempted*
How well does your pet perform?*
Is it working well? *
Exercise #2*
Attempted*
How well does your pet perform?*
Is it working well? *
Exercise #3*
Attempted*
How well does your pet perform?*
Is it working well? *
Are you, any family member, or your pet having difficulty with any parts of your discharge instructions, or are there any recommendations you have been unable to implement? Please explain fully.*
Any additional comments since your pet's last visit:
Number of bites since your last visit?*

012345>5
Number of bites that broke skin?*

012345>5
Number of bites reported to public health authorities? (ie. local authorities, hospital, humane society, etc.*

012345>5
Reported to:
Have you recently considered finding another home for this pet?*

YesNo
Have you recently considered euthanasia? (putting your pet to sleep)*

YesNo
Has someone recently recommended that you euthanize your pet?*

YesNo
Has the behavior service helped you with your pet?*

YesNo
Additional Comments?
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Canine Behavior Recheck Form

Dog Recheck History

Behavior Medications Your Dog Is Currently Taking

Pre-Existing Behavioral Problems

Current Management