Questionnaire behavioural medicine dogs

Questionnaire behavioural medicine dogs

Please complete the following questionnaire as best you can. There are a lot of questions, you don't have to answer them in detail, we will have time for that during the consultation. The main aim is that I have some information in advance and can prepare myself for you and your dog. This will also allow us to focus on the important points and not spend time collecting background information.Thank you in advance for your time!
email address*
example@example.com
date of your initial consultation*

TagMonatJahr
Datum
Stunde MinutenAM/PM Option
Your contact details
name*

first namelast name
address*

Street / house number

zip codeLand

citycountry
Phone number*
Where did you hear from us?

dog trainervet practicevet hospitalfriendsmediainternatother
Your vet practice (name, phone, email address)
Current dog trainer (name, website)

Consent regarding sharing of information:

	yes	no
May we contact your vet practice to receive medical information on your dog?
May we share information regarding your pet with your vet practice?
May we share information regarding your pet with your dog trainer?

Your dog
your dog's name*
breed*
sex*

female not neuteredfemale neuteredmale not neuteredmale neuteredmale chemically neutered
Did you notice any behavioural changes after neutering? If so, please describe briefly
birth date*
current weight (in kg)*
Age at adoption*
How would you describe your dog's personality?
What does your dog love most?*
What are your dog's strengths? What do you particularly love about your dog? *

The current problem
Behaviour: Please describe the current behavioural concern *
Beginning: How old was your dog when the behaviour started? Please describe the first incident you remember.
Development: How has the behaviour developped over time? What has gotten better, what worse and what has stayed the same?
Frequency: How often does the beahviour occur (i.e. times per day or per week or per month or per year)?
Recovery: How long does it take for your dog to recover from a stressful event?

Intensity / level of suffering: On a scale of 1-10, how bad is the current situation for you (= the humans) and for your dog? 1 = absolutely no problem, 10 = worst imaginable situation*

	decgree of suffering (1-10)
for you
for your dog

Reasons: Do you have an idea / a gut feeling as to why your pet is behaving this way?
Treatment attempts: What have you already tried to tackle the problem? How successful were the attempts? What worked, what didn't?
Worries: What is the biggest challenge for you currently? What are you worried about the most?*
Wishes: What do you hope to gain from the behavioral consultation?*
Further information: do you wish to share any further information that may be important regarding your dog's behaviour?

	Behaviour
alone
with dogs in the same household
with familiar dogs
with unfamiliar dogs
with you
with familiar people
with unfamiliar people
with other animals
other

	names, ages and relationship with dog
adults
children
dogs
other animals

	Information regarding your dog's sleep behaviour
Where does your dog sleep at night
Where does your dog sleep/rest during the day?
How many hours per 24h does your dog rest/sleep?
does your dog dream?
Does your dog sleep quietly through the night?

Communication and social behaviour
If you have attended dog training courses with your dog, please briefly describe the type of course(s) and how your dog did during these courses:

Communication: how do you let your dog know when s/he is doing something

	How do you react when your dog is doing something...
...right
...wrong

Aids: Which aids do you use and how does your dog react to these?

	your dog's reaction / how does s/he react to this?
voice
treats
clicker
marker
hand signals
body language
collar
harness
short lead
long lead
head halter
muzzle
other

Learning: How do you think your dog learns?

qucklymediumslowit dependsother
Concentration: How would you consider your dog's ability to concentrate?

How does your dog behave in the following encounters

	your dog's behaviour
dogs within the same household
familiar dogs
unfamiliar dogs
family members
familiar people at home
unfamiliar people at home
familiar people outside the home
unfamiliar people outside the home
children
other animals

How does your dog behave in the following situations:

	your dog's behaviour
new situations (e.g. on vacation, new walks)
Change of routines (e.g. vacation, longterm visitors)
New objects, things that weren't there before (e.g. garbage bags, suitcases)
Many stimuli (e.g. crowds, public transportation, restaurants)
visual stimuli (eg. bicycles, cars, dogs, people)
Sounds (e.g. thunderstorms, fireworks, wind, rain, metallic sounds)
smells (e.g. wildlife, cats, dogs, perfume, fertilizer)
Touch (e.g. petting, harness, collar, coats, manual therapy, clinical exam)
Emotional stimuli (e.g. tense mood, arguments, joy, excitement)
Car (parked, driving)

Further information: Is there any further information you would like to give us?

	never	sometimes	often	used to, but not anymore	I don't know
flight
freeze
seeking your proximity
trembling
excessive barking
howling
growling
snarling
snapping
biting without injury
biting with injury
raising hackles
licking him/herself excessively
scratching him/herself excessively
tail chasing/circling
chasing shadows / lights
restlessness / nervousness
high excitability
excessive panting
panting without apparent reason
hypervigilance
destroying
following you everywhere
Anderes

	never	sometimes	often	excessively	I don't know
fear
panic
anxiety
anger
irritation
frustration
sadness
depression
envy / jealousy
happiness / joy
positive anticipation
contentnment
affection / love
empathy
gratefulness
pride
curiosity
patience
other

	situations	signs / behaviours
stressed
fearful / anxious
aggressive
happy

	current	past
Medication
Supplements
Manual therapies (e.g osteopathy, chiropraxis, acupuncture, Canine Bowen Technique, etc.)
Other

	brand / composition	time of day
dry
wet
cooked myself
raw
other

Questionnaire behavioural medicine dogs

Your contact details

Your dog

The current problem

Your dog's general behaviour

Physical health

Current living environment

Origin and development

Everyday life

Communication and social behaviour

Reports and Further Services

	yes	after a while	no	it depends	not applicable	I don't know
at home alone
at home with you
at home with the whole family
at home with familiar guests
at home with unfamiliar guests
visiting outside the home
in the office / at work
in the car
outside in urban environments (e.g. parc, public transportation, restaurants)
outside in quiet environments (e.g. forrest, fields, etc.)
other

	yes	no
May we make video recordings and take photos of your dog during the consultation?
May we use these recordings for teaching purposes (students / lectures)?
May we use photographs of your dog (without people) for publication purposes, e.g. handouts, any articles or books?