Feeling Pawsitive Canine Intake Form

Feeling Pawsitive Canine Intake Form
The information you provide below will be used by Dr. Hilliard, Resident in the American College of Veterinary Behaviorists, during your consultation to develop a diagnosis and plan of treatment.

Please fill it out as completely as you can.

Please submit this form at least 4 days prior to your pet's appointment date.
Full Name*

First NameLast Name
Spouse Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
How best do you learn new information?

VerbalVisualBoth

Your Family Veterinarian's Contact Information
Family Veterinarian
Hospital Name
Hospital Email
Veterinarian's Phone Number
Do you authorize us to send a summary of the consultation to your family veterinarian?

YesNoDo you authorize us to send a summary of the consultation to your family veterinarian?

Your Dog's Information
Name
Breed
Dog's Birthday
Current Weight
Sex

MaleFemale
Color
Spayed/ Neutered
Age at which spayed or neutered
Date you acquire your dog?
Where did you acquire your dog? (ex: shelter, breeder, friend, etc)
Why did you decide to acquire a dog? (Companion / Protection / Playmate for other dog / Etc)
What made you choose this dog?
How old was your dog when you acquired him/her?
% of time indoors
Of the total time spent indoors how long is the dog in a crate?
% of time outdoors

Behavior History
What is the main behavioral problem or complaint?
How long has this behavior been going on?
How serious would you rank this behavior?

Very seriousSeriousNot seriousOther
How often does this behavior occur?

DailyWeeklyMonthlyOther
Please give a detailed description of the most recent incident. Please include dates of occurrence
Please give a detailed description of the very first incident you remember. Please include the date
How old was your dog when he/she first began showing signs of this behavior?
Have there been changes in frequency or exhibition of the behavior problem?
What steps have been taken to resolve the behavior problem?
What will you do if this behavior cannot be corrected?
Please list any other behavior problems
What is your goal for this consultation? What would you like to see accomplished?

Medical History
Please describe any previous or current medical problems of the dog
Is your dog currently on any medication or special diet?

YesNo
Please list all current medications including heartworm, flea and tick prevention
Please list all vaccines given within the last year (include dates given)

	NR	M	B	G	SL	SN	BT	ND
Type of Behavior - Take dog’s meal away while he/she is eating
Being able to add food to bowl while dog is eating picked up
Pet the dog
Trim the dog's nails
Lift or try to lift the dog
Grab dog by collar
Hug or kiss dog
Scold dog verbally
Restrain
Push on dog's back
Bathe dog
Push on dog's rump
Wash dog's face
Wake dog when sleeping
Take away dog's favorite toy

	Never	Rarely	Occasionally	Frequently	Almost Always
Do you feel you don’t have enough time for yourself because of the time you spend caring for your pet?
Do you feel stressed between taking care of your pet and trying to meet other responsibilities for your family or work?
Do you feel embarrassed by your pet’s behavior?
Do you get angry when you are around your pet?
Do you feel that your pet currently negatively affects your relationship with other family members or friends?
Are you afraid of what the future holds for your pet?
Do you feel tense when you are around your pet?
Do you feel that your health has been affected because of your involvement with your pet?
Do you feel that your social life has been affected because you are taking care of your pet?
Do you feel uncomfortable having friends over because of your pet?
Do you feel that you don’t have enough money to take care of your pet in addition to the rest of your expenses?
Do you feel that you won’t be able to take care of your pet for much longer?
Do you feel that you have lost control of your life since your pet’s illness?
Would you prefer to leave the care of your pet to someone else?
Do you feel uncertain about what to do regarding your pet?
Do you think you should do more for your pet?
Do you think you could take better care of your pet?
Overall, to what extent do you feel overwhelmed in taking care of your pet?

Your Family Veterinarian's Contact Information