Behavior History Form

Behavior History Form
Eagle Animal Hospital

4825 NW Gateway Avenue Riverside, MO 64150
Owner Name
Date

MonthDayYear
Date
Primary Phone
phone
Email
example@example.com
Primary Care Veterinarian
Referred by
Pets Name
DogCat
MaleNeuteredFemaleSpayed
Breed
DOBAGE
Age at which neuteredspayed
Where did you get your pet
What age did you get your pet
How long have your had your pet
Has your pet had other owners
How many that you are aware of
Please provide any additional information about previous ownershomes
How many people are in the household?
children
under 18 list ages
Are there any children under 18 who come to visit regularly
Has there been any significant change in your households routine or schedule in the past 3 mos
What are your goals for this appointment
How many play sessions does your dog get per day
Tell us about your pets enviroment

Leashed walkedDog ParkTie OutFenced YardChain link or Iron FenceSolid wood fenceInvisible fenceOther
Is the pet left alone during the day?
How long
Where does your pet spend time in the following situations?
Family home
Family away
Family asleep
When guests visit
What describes your pet's personality?
What toys/types of play does your pet enjoy
What amounttype of exercise does your pet get dailyweekly
If you have multiple pets, please answer the following questions:

Sleeps with your other petsGroom (licks) other petsPlays with your other pets
List the other animals in the household and describe their relationship with the patient
Has your dog had any formal obedience training?

YesNoGroup classPrivate TrainingI trained myself
What type of collar do you use for training?

FlatChoke ChainPinch/prongHead HalterMartingaleHarness
What commands does your pet know
Grade the success of training:

ExcellentGoodFairFailed
Does your dog get along with other dogs?

YesNo
If no, Please explain:
How does your dog react to unfamiliar people
Medical History
Please describe any significant medical illnesses, treatments, and the outcome.
What do you feed your pet
Does your pet have any allergies or food sensitivities
Does your dog lick (you, the floor, himself, other objects, other people)excessively?

YesNo
Please list all medications and supplements your pet is taking
Scientific studies have shown a strong connection between gut health and brain health. Please answer the questions below regarding your dog's gastrointestinal tract health.

Please note how often your dog has any of the signs below:

	Daily	Weekly	Monthly	Several times a year	Never
Vomiting
Diarrhea
Constipation
Decreased appetite
Excessive licking
Lip licking

Please list all previous medicationssupplements you have tried that your pet is no longer
Please Describe your pets behavior problems
When was the problem first noted
Where and under what circumstances was each problem first noted
Describe the situations in which the problem is most likely to occur
times per day
times per week
tiems per month
Has there been a change in the frequency or intensity of the problem
Please describe
What has been done so far to correct the problem
What was the pets response to the correction
Please describe all situations which are likely to elicit aggressive behavior growling nipping biting attacking
Has your dog ever bitten a person?

YesNo
Please describe the circumstances
Has your dog ever bitten another dog/cat?

YesNo
Please describe the circumstance
If you pet has an aggression problem describe 23 of the aggressive incidents in detail
Any additional information that you feel is relevant to your pets behavior problems
Should be Empty:

Behavior History Form

Eagle Animal Hospital

Medical History