Dog Behavior History

Dog Behavior History Form
Person Information
Primary Caregiver Full Name*

First NameLast Name
Please select one or more options for the set(s) of pronouns you want people to use to refer to you:

she, her, hershe, him, histhey, them, theirsOther
Email*
example@example.com
Phone Number*

Area CodePhone Number
Other owner/caregiver name and pronouns
Other Email
example@example.com
Other Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip
Pet Information
Dog's Name*
Breed or mix *
Weight
Current Age*
Sex*

Spayed FemaleIntact FemaleNeutered MaleIntact Male
Is this dog microchipped?

YesNoUnsure
Microchip number if known
Where did you get this pet?*
What do you know about this pet's history?
How long has this pet lived with you?*
Family Make Up
HUMANS (living with, frequently visiting, etc.)
PETS (living with, frequently visiting, but not directly involved in behaviors)
Are any other pets DIRECTLY involved in the concerning behaviors?*

NoYes, 1 other petYes, 2-3 other petsYes, 4-6 other pets
2nd pet directly involved
3rd pet directly involved
4th pet directly involved
5th pet directly involved
6th pet directly involved
The Behaviors
Describe the most concerning behavior you wish to address *
Are there other concerning behaviors you wish to address?

NoYes, one other behaviorYes, two other behaviorsYes, three other behaviors
Describe the 2nd most concerning behavior you wish to address
Describe the 3rd most concerning behavior you wish to address
Describe the 4th most concerning behavior you wish to address
Provide any additional behaviors and/or information.
Training History
How do you typically correct unwanted/bad behavior?

Physical (Spanking, nose tap, etc)Verbal (Scold, No!, AhhAhh!, Tsst!, etc)Noise (Squirt bottle, penny can, clap hands, etc)Leash jerk / popElectronic collarI don'tOther
How do you typically reward good behavior?

Affection (praise, petting, etc.)TreatsI don'tOther
Please list any trainers you have worked with in the past.
What have you specifically tried to resolve the problems in the past?*
How did the behaviors change in response to what you described above?

Got worseGot betterNo changeUncertainOther
Health, Nutrition, Exercise
How many hrs/day is dog alone on average?
Describe type, amount, and intensity of exercise
Name of your vet clinic and the vet you prefer (if any).*
Did your vet give you any recommendations for your concerns?*
Date of most recent exam and notable comments*
Proof of rabies vaccination (file must be under 1024KB. If file doesn't upload, clear this field to allow form submission)

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Any other relevant records

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List any current, recent, or past injuries or illnesses*
List any medications, supplements, etc. *
List any food or environmental sensitive or allergies*
What brand/kind of food does your dog eat?
Describe feeding routine (check all that apply)

Feed at scheduled times, finishes right awayFill bowl at scheduled times, grazes throughout dayFood is always availableDry kibbleCannedRaw or homemadeScraps or left over people foodOther
Do you have pet insurance?

YesNo
House Soiling Information
Is your dog having house soiling issues?*

Never (unless rare circumstances like illness)Yes or sometimes
WHERE is your dog eliminating?

In the crateOn the hardwoodsOn tile or linoliumOn carpetOn laundry, blankets, throw rugs etc.On furnitureOther
WHAT is your pet doing?

Hiding from meLifting leg to urinateEating fecesChewing on or dragging bumModerate to large urine puddlesTiny to small urine puddlesDrops of urineLarger than expected bowl movementsParticularly bowl movements
Aggression Information
Has your dog growled, air snapped, attempted to bite, or bitten?*

NoYes
Which of the following have you seen?*

Air snap, no contactBruising or skin dentsScratched skin or some bloodShallow puncture(s)Deep puncture(s)Multiple bites in one incidentMedical attention required for victim
Who is the aggression directed toward?*

An adultA childA catA dogFamily member that lives/lived in home"Friend" of the dog that doesn't live withStrangersOther
Where is the aggression occurring?*

Inside the homeOut of house windows/doorsOutside on propertyWhen leash walkingWhen off leashWhen in the carWhen away from homeAt the vet, groomer, etc.Other
Describe the circumstances of the most severe incident*

Dog Behavior History Form

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