Behavior Questionnaire
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Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best Time of Day to Reach You
Email
example@example.com
How did you hear about us?
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Pet Information
Please list the other household pets:
Rows
Name
Species/
Breed
Spayed/
Neutered
DOB/
Age
Pet 1
Pet 2
Pet 3
Pet 4
What concerns do you have with your dog(s)?
Aggression towards people in household
Aggression towards other pet(s) in household
Aggression towards people outside the household
Aggression towards other pet(s) outside the household
Separation Anxiety/Separation Related Behaviors
Fear Issues
Excessive Vocalization
Noise Phobias
Husbandry- nail trims, grooming, vet visits, etc.
Other
If you listed "Other", please tell us more.
Has your dog ever nipped or bitten another dog or person?
Yes
No
If so, please give us as much information about the situation as possible. Where did it happen? What was the environment like prior to the bite/nip? Was there any broken skin to the dog or person?
Please tell us a bit more about the dog(s) history. How long have you had the dog? Where did you get the dog from?
Does your dog have any known health issues?
Is your dog currently on medication?
Yes
No
If so, tell us the name, dose and how frequently they are receiving it.
Please let us know how you feel about using medications for your pet’s behavior problem:
I wish to use behavior modification alone to improve my pet’s behavior
I wish to use behavior modification alone but will consider using medication if it is recommended
I wish to use a combination of behavior modification and medications to improve my pet’s problem
I fully anticipate using medications to improve my pet’s problem
Primary Care Vet Hospital/Clinic
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Prior Training
Does your dog have any prior training?
Yes
No
Training Done:
At Home
Puppy Class
Board & Train
Obedience Classe(s)
Private Lessons
Other
Describe any other training not listed:
Have/do you use any of the following?
Clicker
Toy Rewards
Choke Collar
Prong/Pinch Collar
Remote/shock training or bark collar
Alpha rolls, grabbing scruff/jowls
Spray water bottle or penny/shaker can
Other
Please list anything else not mentioned above:
Is your dog crate-trained?
Yes
No
Describe in as much detail as possible, the specific behavior problems you want to address:
What have you tried to solve the problem? Please provide as much detail as possible.
How much time are you realistically willing to invest in solving the problem?
Are you considering re-homing this dog if you are unable to fix the problem behavior?
Yes
No
It has been a thought
Are you considering euthanizing this dog if you are unable to fix the problem behavior?
Yes
No
It has been a thought
Is there any other information you think we should know?
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Should be Empty: