Behavior History Form

Canine Behavior History for Risk Assessment and Training - My Sidekick Dog Training

We appreciate you taking the time to fill out this form thoroughly. This form may take 90 minutes to complete. If you get started on this form and do not have time to complete it, you can click "save" at the bottom of the page at any time and you will receive a link in your email to complete it later. This link will likely be sent to the spam folder. Make sure you've received the link before you leave the page. Alternately, you can click "copy link" and save it somewhere so you do not loose it. Once the form is submitted, you will be redirected to a page where you can select a time for the appointment.
Dog's Name*
Shelter or Rescue Organization Name
Your name*

First NameLast Name
Your pronouns
Pronouns are the words we often use to talk about a person when we’re not using their name. These might be he/him, she/her, they/them or other pronouns. Some people use one set of pronouns (eg. Pablo uses he/him pronouns) and some people use more than one (eg. Samira uses she/her and they/them interchangeably). Our trainer Ash uses both they/them and she/her. Some people change the pronouns they use at different points in their life, and making sure we use their new ones is an important part of respecting them. Please feel free to let us know if your pronouns change at any time. Because we can’t always tell someone’s gender just from looking at them, we can’t really know what pronouns to use for someone until we ask them.
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Email*
example@example.com
Shelter address or your address, if dog is foster care at your home

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suspected or known breed(s)
Dog's Photo

Cancelof
Dog's estimated age*
Dog's weight*
How long the dog has been under the care of your organization*
# of weeks, months, or years
Sex*

Spayed FemaleNeutered MaleIntact FemaleIntact MaleIntersex
Organization's Veterinarian
Would you like to allow the use of photo and video of the dog's behavior assessment and training on social media or in educational content?*

YesNoMaybe, we can discuss

What is the primary behavior of concern? *
Chronology of the Behavior Problem
Additional behaviors of concern (please list)*
How frequently is the primary behavior of concern occurring? (how many times daily, weekly, or monthly) *
How frequently are the other behaviors occurring? *
In what general circumstances do the behaviors occur?*
Have the behaviors changed in frequency and/or intensity? Please describe
Please describe the most significant incident in detail
Please describe the second most significant incident in detail
Please describe the third most significant incident in detail
Other significant incidents
What interventions have been implemented so far to address the dog's behavior?
Training, management, medication, enrichment, etc

Dog's Background
How did your organization acquire this dog? (Shelter/Rescue Transfer, Owner Surrender, Stray, other?) *
If any background information on the dog is known, please describe.
How many people can interact with and handle the dog without issues?
How does the dog behave with familiar people?
How does the dog behave with unfamiliar people?
Please describe how the dog has interacted with other dogs, if known

Diet and Feeding
Any known allergies?
How is the dog fed their meals? Bowl, slow feeder bowl, puzzle toys, etc
Has the dog's appetite:

IncreasedDecreasedUnknown or No change
How quickly does the dog finish their food?

Immediately, as fast as they canImmediately, at a regular paceImmediately, at a slow paceWithin a few hoursFree feeds- bowl is always full

Dog's Routine (if in a foster home)
If known, please describe any concerning behavior when left alone (vocalizing, urinating/defecating, pacing, biting or scratching at door, etc).
How does the dog behave when separated and confined to a crate or a room?
Where is the dog when you have guests at the home?
How often do you have guests at the home?

Dog's Training
If known, has the dog had any training? (None, trained at foster home, worked with private trainer, went to group class, etc?)
Where or with whom did the dog train?
What has been used in training for this dog? (No judgement! Just gathering information.)

Food treatsFlat collarMartingale collarHarnessProng CollarChoke CollarElectric CollarSlip leadOther
What equipment (type of collar/harness/leash) do you use presently for the dog?

Medical information
Has the dog had or currently have any medical conditions or health issues? This includes ear, skin, sensory issues, changes in appetite and weight, lethargic behavior, seizures, surgeries, illnesses, etc. Please describe.*
Is the dog on any medication now, for this or other problems? If so, please list specific medication names, doses, and frequency. Please also list any heartworm prevention, flea and tick prevention, medicated shampoos, etc.
Has the dog been on medication in the past? If so, please describe.
Is the dog on any supplements? Vitamins, herbs, etc.
When is the dog due for a rabies vaccination?

Compulsive Behavior Screen

Please fill out to the best of your ability
Please select any behaviors the dog performs

Light or Shadow Chasing/StaringLicking Surfaces - walls, glass, doors, floors, fabric, furnitureLicking Self ExcessivelyTail ChasingFlank SuckingWool/Blanket/Toy/Pillow SuckingFly Snapping (no fly present)Predatory chasing/pouncing at something that isn't there
Please describe the frequency and intensity of any of the behaviors you selected

Canine Behavior History for Risk Assessment and Training - My Sidekick Dog Training

Chronology of the Behavior Problem

Dog's Background

Diet and Feeding

Dog's Routine (if in a foster home)

Dog's Training

Medical information

Compulsive Behavior Screen

Fear and Aggression Screen

Please indicate the dog's reaction to each of the listed scenarios. If their behavior has changed over time, please check all of the responses that you know have occurred at some point.

Thank you for taking the time to complete this questionnaire. After clicking “submit” you will be redirected to a page where you can schedule a time to meet.