Behavior Questionnaire

Canine Behavior Questionnaire

(This form is adapted from "Manual of Clinical Behavioral Medicine for Dogs and Cats" by Dr. Karen L. Overall and is for the exclusive use of clients of Veterinary Relief and Behavior, LLC)
Please answer these questions to the best of your ability. The more specific information you provide, the better we can help you and your pet! This form will likely take you 30-45 minutes to complete, and can be completed in more than one sitting. You can save your progress and come back to it later by clicking the "SAVE" button at the bottom of the screen. (You do not need to click the save button between sections unless you are taking a break.)

NOTE: If you have multiple pets that you would like behavior consultations on, please fill out a SEPARATE form for each pet. At the end of this form it will give you an option to pre-fill your contact info for your second pet's form. If one of the pets is a cat, then please make sure to use the feline questionnaire on our website. Thank you!
If you want more information about veterinary behavior consultations with Dr. Edwards, or if you have pricing questions, you can find that information here:

https://www.drstevenedwards.com/owners

https://www.drstevenedwards.com/questionnaire-links
YOUR Name*

First NameLast Name
Email*
example@example.com
Address – this is where we will meet if doing an in-home consultation.*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number – (CELL phone is preferable so we can text you about your pet)*
Please enter a valid 10 digit phone number.
Name of spouse/partner (if applicable)
Email of spouse/partner (if applicable)
example@example.com
Phone of spouse/partner (if applicable)
Please enter a valid 10 digit phone number.
What is the COMPLETE NAME of the veterinary hospital you take your pet to? (This is where we will request medical records from, and where we will send a copy of your behavior reports.)*
What CITY is this hospital located in?*
There are many animal hospitals with similar names, so this helps us make sure we're contacting the right one!
Who is your pet's primary doctor at that hospital?
We will request medical records for your pet from your veterinarian(s). Are there any OTHER hospitals (besides the one listed above) that have recently treated your pet?
Also, is there any other name (e.g., married name) or phone number that an animal hospital might have your pet's records listed under?
Who referred you to Dr. Edwards?
Date of form completion (i.e., today's date)

MonthDayYear
Date
Your pet's name (REMINDER: if seeking a behavior consultation on MULTIPLE pets, please complete a SEPARATION QUESTIONNAIRE for each pet)*
One pet per form, please
Breed of dog
Dog's gender*
Is this patient neutered/spayed?*
Dog's date of birth:*

MonthDayYear
If not sure, round to nearest year
Check here if date of birth is an estimate
Dog's body weight (in POUNDS)
Date you acquired your dog:*

MonthDayYear
If not sure, round to nearest year
Has this pet had previous owners?*
If previous owners, why was this pet relinquished?
Where did you get this pet?

Stray/found itBreeder (serious show/performance breeder)Breeder (backyard breeder or neighbor)Rescue organization or shelterPet StoreOther
Why did you get this dog?
Does your dog have any medical or physical problems that your veterinarian has noted?
Is your dog currently on any flea/tick prevention or heartworm prevention? If so, which one(s)?*
Is your dog taking any other medications or supplements right now? If so, what doses, how frequently, and for how long?*
Has your dog ever been treated before with any behavioral medications or supplements? If so, please elaborate. What effects did they have?*
What food and what treats (if any), does your dog receive?*
Does your dog have any feeding restrictions? (i.e., are there any treats that I should NOT bring to your dog's behavior consultation?) If so, please elaborate.*
Does your dog exhibit periodic diarrhea or gastrointestinal distress (i.e., intermittent STOMACH UPSET)? If so, please explain.
Please describe an average day for your dog, with times that they/you wake up, when they are fed, when they are typically let out, etc. (We know this might vary significantly from day to day, but whatever information you can provide could be helpful)
Has your household changed since acquiring this pet?*

Another pet added to the familyFamily movedFamily schedule changed (e.g., change in work schedule from a new job)MarriageBaby was bornChild or family member moved out of/into houseDeath of human in familyDeath of pet in familyDivorceNo changes
If yes, WHEN did EACH of these changes occur?
If you have any UPCOMING changes, what are they and when will they happen?
Were any littermates, parents, or other relatives of this dog known to have any MEDICAL or BEHAVIORAL problems?

Previous pet experience...

	Yes	No
Have you owned CATS before?
Have you owned DOGS before?

Please list ALL the people, INCLUDING yourself, currently living in the household*

	Name	Relation	Gender	Age	Occupation
You
2
3
4
5
6
7
8

Please list all the PETS currently living in the household*

	Name	Species	Gender	Spay/Neutered?	Age	Date joined household
Patient
2
3
4
5
6
7
8

Any special circumstances related to the living situation?
Let us know if a family member or pet is only with you for part of the year, for example.
Do any of the other pets listed above (excluding the primary patient) have previously diagnosed MEDICAL problems? If so, please explain.
Do any of the other pets listed above (excluding the primary patient) have previously diagnosed BEHAVIORAL problems? If so, please explain.

Problem Behaviors
Problem #1a: Please state the MOST important behavioral problem/complaint.*
Problem #1b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?*
Problem #1c: Approximately when did you first notice this problem?*

MonthDayYear
Date
Problem #2a: Please state the second-most important behavioral problem/complaint.
Problem #2b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?
Problem #2c: Approximately when did you first notice this problem?

MonthDayYear
Date
Problem #3a: Please state the third-most important behavioral problem/complaint.
Problem #3b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?
Problem #3c: Approximately when did you first notice this problem?

MonthDayYear
Date
Problem #4a: Please state the fourth-most important behavioral problem/complaint.
Problem #4b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?
Problem #4c: Approximately when did you first notice this problem?

MonthDayYear
Date
Problem #5a: Please state the fifth-most important behavioral problem/complaint.
Problem #5b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?
Problem #5c: Approximately when did you first notice this problem?

MonthDayYear
Date

Additional Information
Please review these key points to ensure the best outcome for your pet. Check each box to confirm that you have read them and understand.
Behavioral treatment is a process, not a one-time fix. Most issues are managed over time rather than completely resolved. Success requires ongoing adjustments and follow-up care.*

I understand
Follow-up appointments are essential. The first follow-up is usually 2-3 months after the initial consult. After that, follow-ups will be every 2-12 months (depending on progress, and client communication/updates).*

I understand
In some cases, medications can be a critical part of achieving improvement and reaching your behavior modification goals.*

I understand
Regular updates are key to behavioral management. Medications often need to be adjusted over time. Also, staying in touch can reduce the number of follow-up appointments needed.*

I understand
Is there anything else you think we should know?
What are your goals for this behavior consultation? In other words, what outcome would you like to achieve for your pet?*

	Yes	No
Are you concerned that you may have caused the problem(s)?
Do you feel guilty about this problem?
Have you considered finding another home for your dog?
Have you considered bringing your pet to a shelter?
Have you considered euthanasia (putting your pet to sleep)?

	ALWAYS	MOST of the time	about HALF of the time	LESS than half of the time	NEVER	I don't know
Destructive
Urination
Defecation
Vocalization
Salivation
Panting
Shaking

	ALWAYS	MOST of the time	about HALF of the time	LESS than half of the time	NEVER	I don't know
Destructive
Urination
Defecation
Vocalization
Salivation
Panting
Shaking

	Salivate	Urinate or Defecate	Try to Escape	Pace	Hide	Freeze	Pant	Vocalize (e.g., bark, whine, howl)	Shake	Destruction (e.g., chew on things)
Thunderstorms
Fireworks
Other noises (if applicable)

	Yes	No	I'm not sure
Wind
Darkness
Rain

Canine Behavior Questionnaire

Problem Behaviors

Behavioral Concerns

Problem Development

Screening Questions

VIRTUAL absences

ACTUAL absences

Noise Screen

Reactivity/Aggression Screen

Previous Treatments

Stereotypic and Ritualistic Behavior - READ INSTRUCTIONS BELOW

Questionnaire for Senior Dogs - READ INSTRUCTIONS BELOW

Additional Information

	Bark (AGGRESSIVELY)	Growl	Snap (doesn't connect with skin)	Bite	Withdraw/Avoid
Take dog's food dish (w/ food)
Take dog's food dish (empty)
Take dog's water dish
Take food (human) that falls on floor
Take bone or other high value food
Take small treat or other low value food
Human approaches dog while eating
Dog approaches dog while eating
Take toy
Human approaches while dog playing w/ toy
Dog approaches while dog playing w/ toy
Human approaches/disturbs dog while sleeping
Dog approaches/disturbs dog while sleeping

	Bark (AGGRESSIVELY)	Growl	Snap (doesn't connect with skin)	Bite	Withdraw/Avoid
Reach toward dog
Push dog off bed/couch
Put on leash
Touch feet
Trim nails
Bathe dog
Dog at groomers
Dog in vet's office
Dog in boarding kennel

	Bark (AGGRESSIVELY)	Growl	Snap (doesn't connect with skin)	Bite	Withdraw/Avoid
Stranger knocks on door
Stranger enters room
Dog in car and sees people outside
Dog on leash and approached by other dog
Dog on leash approached by person on street
Dog yelled at (do NOT test this; asking in case you already know the answer)
Dog corrected with leash (do NOT test this; asking in case you already know the answer)
Dog physically hit (do NOT test this; asking in case you already know the answer)
Someone raised voice to owner in presence of dog
Someone hugs/touches owner in presence of dog
Squirrel/cat/small animal approaches dog
Bicycles, skateboards
Crying infant
Playing with children <2 yrs old
Playing with children 2-5 yrs old
Playing with children 6-11 yrs old
Playing with children 12-16 yrs old

	Yes, CURRENTLY using this technique.	I used this in the past, but not anymore	Never used/tried
Metal choke collar
Fabric choke collar
Martingale Collar
Prong collar (a.k.a. "pinch" collar)
Head collar (e.g., Gentle Leader, Halti, etc.)
Step on leash or choke collar and force down to floor
Electronic/shock collar - controlled by owner
Electronic/shock collar controlled by trainer
Electronic/shock collar - bark activated
Citronella or spray collar
Stare at or "stare down"
Shaker can (e.g., throw a tin or can of pennies to startle dog)
Spray bottle
Whistle
Foghorn
Knee dog in chest/belly
Hit dog with hand
Hit dog with another object
Kick dog
Bite dog
"Alpha roll" (hold spread eagle on back)
Dominance down (hold down on sides, legs extended, head flat)
Growl at dog
Yell or scream at dog
Separate in different room
Separate in crate
Praise for good behavior
Kennel outdoors
Fenced yard
Invisible fence
Board at vet's or kennel
Pop, jerk, or yank on leash
Muzzle
Increase exercise
Increase play
Give treats for good behavior
Deprive of food
Shove dog's nose/face into urine/feces/destroyed item
Use scat mats or other electronic avoidance systems

	Yes	No	Unknown
Chewing self
Licking self
Barbering/trimming hair on self
Suckling on own skin (e.g., dog holds leg in its mouth but doesn't chew)
Biting self
Plucking hair from self

	Yes	No	Unknown
Staring at and attending to things that are not real
Tracking things that are not real
Pouncing on or attacking things that are not there

	Yes	No	Unknown
Consuming rocks
Consuming dirt or soil
Consuming other objects
Chewing/eating on fabric, rugs, clothing, bedding
Licking/suckling (but not chewing) on fabric, rugs, clothing, bedding
Licking or gulping air

	Yes	No	Unknown
Circling/spinning WITHOUT focus on tail
Tail-chasing (with or without grabbing it)
Freezing and staring at unknown focus

	Yes	No	Unknown
Rhythmic barking - NOT at any specific object/thing
Rhythmic howling - NOT at any specific object/thing
Rhythmic growling - NOT at any specific object/thing

	More than once a day	Once a day	Once a week	Once a month	Never
Walk in circles, pace, or wander with no direction or purpose?
Stare blankly at the walls or floor?
Get stuck behind objects and is unable to get around them?
Fail to recognize familiar people or pets?
Walk into walls or doors?
Walk away from/avoid being petted or receiving other loving attention they used to enjoy?