Behavior History Form

Owner Name

Date

Primary Phone

Format: (000) 000-0000.

phone

Format: (000) 000-0000.

Email

example@example.com

Primary Care Veterinarian

Referred by

Pets Name

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

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:

List the other animals in the household and describe their relationship with the patient

Has your dog had any formal obedience training?

What type of collar do you use for training?

What commands does your pet know

Grade the success of training:

Does your dog get along with other dogs?

If no, Please explain:

How does your dog react to unfamiliar people

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?

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:

Rows	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?

Please describe the circumstances

Has your dog ever bitten another dog/cat?

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

Behavior History Form

Eagle Animal Hospital

Medical History