Canine History Form for Case Review
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Overview
Individual completing this form.
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Pet's name
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Pet's approximate age or date-of-birth, sex, spay/neuter status, breed or breed mixture, & most recent weight.
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Ex: 2 year old, neutered male, Pembroke Corgi, 29 lbs.
Photograph of pet
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Veterinary Clinic, Doctor, and Telephone Number
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Consent to Use Medical Information for Professional Development
I hereby consent to the disclosure of my pet's medical and behavioral information to Mindful Mentor Behavior Consulting, LLC. for the purpose of discussing their condition with verified veterinary professionals. My personal information such as full name, address, and telephone number will NOT be used during this discussion, but my pet's identifying information will be. I understand that all participants in the webinar are required to sign a confidentiality clause preventing them from using this information without written consent from me. I have the right to withdraw my consent at any time. This consent is valid for 90 days from time of signing.
Signature
Today's date
Acquisition & Early History
How did you acquire this dog?
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Breeder
Shelter
Rescue
Friend or family member
Other
What is the pet's history prior to acquisition?
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Approximate date and age of acquisition?
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If spayed or neutered, at what age was it performed?
How much interaction did this dog have with people and other animals during their first year of life?
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Briefly describe your pet's personality.
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Describe the problem(s) you are currently having.
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When did this start?
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What has been tried to correct the problem?
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Do you suspect any cause?
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Describe the last three incidents or episodes.
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Describe the dog's body posture during these episodes.
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What was your (or your family's) response to these episodes?
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What was your dog's reaction to your response?
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If there were aggressive behaviors, what was the result to the victim? (Check all that apply)
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Not applicable
No contact, just posturing
Bruise
Scratch
Shallow puncture (Less than 0.5 inches deep)
Deep puncture (Greater than 0.5 inches deep)
Tearing
Required medical treatment
Other
Are there any other pertinent details or comments you would like to share? There will be a broader section exploring aggression later in this form.
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Medical History
What do you feed your dog? Please provide name/formula, quantity fed, frequency of feeding, & crude protein percentage on the bag.
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Ex: Science Diet Adult Small Bites - 1/3 cup twice daily.
How would you describe your dog's appetite? Select all that apply.
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Poor, very picky
Good, eats normal
Voracious, always eating
Consistent
Sporadic
Please provide information about any routine products, medications, or supplements:
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Name/Description
Amount/Dose
Frequency
Comments or Response
Preventatives
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
Please provide details about any chronic medical conditions your dog has, incuding diagnosis & treatment.
From the list below, please check any ailments your pet has experienced within the last year.
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Coughing
Sneezing (excessive)
Eye discharge
Nose discharge
Vomiting or regurgitation
Diarrhea or soft stool
Lameness or limping
Changes in activity level
Seizures
Surgery (besides spay/neuter, if applicable)
None of the above
Other
Does your pet have a relationship with any of the following veterinary specialists?
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Internal Medicine
Surgery/Orthopedics
Rehabilitation/Physical Therapist
Chiropractor and/or Acupuncturist
Ophthamologist
Dermatologist
Oncologist
Behaviorist
Other
Not Applicable
If you selected any of the above, please provide their name, facility, and telephone number.
Household & Daily Life
Please list the human occupants living in your home, whether part or full time.
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Name
Age
Occupation
Relation to you
Relationship (how they get along) with this dog
Yourself
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
Please list any other pets or animals living in your home, excluding the patient.
Name
Age
Sex, spay/neuter status
Species & Breed
Relationship (how they get along) with this dog
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
In what sort of home do you and your pet reside?
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Single Family Home
Townhouse
Condo/Apartment
Other
How would you describe the energy in your home?
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Quiet, slow, routine oriented
Moderate activity, some sporadic changes
High activity, lots of coming & going, noisy
Have you owned a dog in your adult life prior to this one?
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Yes
No
How do you feed your dog?
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Out of a bowl
Feeder toys
Puzzle toys
As part of training
Other
Where does your dog eat in relation to other pets in the household?
Do you need to be present for your dog to eat?
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Yes
No
Sometimes
Is your dog protective of their food?
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Yes
No
With family members
With children
With strangers
With housemates
With visiting pets
Where does your dog spend most of their day?
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Where does your dog sleep at night?
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In a 24 hour period, how much does your dog sleep?
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How does your dog ask to go outside?
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How many times does your dog go outside per day?
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How long does you dog like to be outside?
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Do you have a yard? If yes, check all that apply:
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Yes
No
Unfenced - goes out off leash
Unfenced - goes out on leash/tether
Electric fence with associated collar
Fenced, but can get through, over, or around
See through fencing (picket, wire, etc.)
Privacy fencing
Small (Less than 0.25 acres)
Medium (0.25 - 1 acre)
Large (Greater than 1 acre)
Does your dog run and bark at the fenceline?
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Yes
No
Not applicable
Chases people
Chases dogs
Chases wildlife
Chases moving objects
What type of physical exercise does your dog get on a regular basis?
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None
1-3 sessions per day
4-6 sessions per day
>6 sessions per day
Short walk (0.25 - 1 mile)
Long walk (> 1 mile)
Jogging/Running
Treadmill
Fetch
Wrestling
Tug-of-war play
Agility
Other
Is your dog playful?
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Yes
No
Sometimes
Is your dog affectionate or cuddly?
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Yes
No
Sometimes
Does your dog like to chew?
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Yes
No
Sometimes
Do they ever destroy their toys?
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No
Yes
Sometimes
Any inappropriate chewing?
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Yes
No
Sometimes
Any additional details around play, chewing, etc?
Where does your dog stay when no one (no people) is home?
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What does your dog do as you prepare to leave?
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Do you record or monitor your pet when they are home alone?
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Yes
No
Sometimes
What is the average length of time your pet might be left home alone?
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Does your dog exhibit any of the following behaviors as you are preparing to leave or once you are gone?
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Pacing and/or panting for extended periods of time
Vocalization including whining, crying, barking, howling
Destruction of doors, windows, or walls
Chewing and destroying inappropriate objects
Urination and/or defecation
Excessive drooling
Vomiting
None of the above
Training & Learning History
How would you describe your dog's ability to learn?
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Poor
Average
Excellent
Is there any specific time devoted to training each day?
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Yes
No
Have you ever attended any professional, group classes?
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Yes
No
Have you ever worked with a private trainer?
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Yes
No
Has your dog ever gone to a board and train facility?
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Yes
No
Have you ever met with a veterinary behaviorist, animal behaviorist, or other behavior consultant?
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Yes
No
If yes to any of the above, please provide details about the individual's name and/or company, topics or skills covered, and any other pertinent information.
Which cues or commands does your dog respond to reliably?
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Come
Sit
Down
Stand
Leave it
Drop it
Off
Wait or stay
Place or settle
None
Other
Does your dog pull on the leash?
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Yes - Always
Yes - Sometimes
Yes - Rarely
No - Use trainer collar(s)
No - Never pulls
No - We don't go for walks
How do you correct your dog when they misbehave?
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What training aids are you CURRENTLY using?
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Treats
Flat collar
Martingale collar
Body harness
Head collar/Halti/Gentle Leader
Slip collar/chock chain
Metal prong/pinch collar
Plastic prong/pinch collar
Vibration collar
Vibration/electronic/stim collar - underground fence only
Vibration/electronic/stim collar - remote operated
None
What training aids have you used PREVIOUSLY?
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Treats
Flat collar
Martingale collar
Body harness
Head collar/Halti/Gentle Leader
Slip collar/chock chain
Metal prong/pinch collar
Plastic prong/pinch collar
Vibration collar
Vibration/electronic/stim collar - underground fence only
Vibration/electronic/stim collar - remote operated
None
Any other comments pertaining to training?
Miscellaneous Behaviors
Does your dog demonstrate aggressive behaviors in any of the following circumstances? (Aggression is defined as any "distance increasing behavior" and can include stiffening, staring, growling, snapping, biting, etc.)
Primary owner
Co-owner
Children
Other people
Handling/Grooming
Petting/Hugging
Disturbing while resting
Disciplining
Taking away food
Taking away objects
Describe your dog's response in the following situations.
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Inside the home
Outside the home
Frequent Visitors
Occasional Visitors
Unknown females
Unknown males
Unknown children
Unknown dogs (on leash)
Unknown dogs (off leash)
Crowds/busy areas
Trucks, buses, cars, etc.
Any urination or defecation when the family is home or away?
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Yes
No
Urination
Defecation
When home alone
When family is home
Any distress associated noises, storms, or fireworks?
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Yes
No
Sometimes
Thunderstorms
Fireworks
Other
Does your dog demonstrate any inappropriate sexual behavior?
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Yes
No
Is your dog protective of any part(s) of their body?
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Yes
No
Does your dog ever demonstrate any of the following behaviors?
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Chases lights or reflections
Chases shadows
Chases their tail/spins
Suckles on blankets
Excessively lick themselves
Excessively lick others
Excessively lick other surfaces
Cause injury to themselves from licking or chewing
Masturbate
Attack the TV
None of the above
Are there any other behaviors your find objectionable?
Perspective & Expectations
Using the scale below, how would you rank your dog's overall behavior? 1 meaning the dog needs to be out of the house ASAP and 10 meaning they are perfect and nothing needs changing.
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1
2
3
4
5
6
7
8
9
10
What is the family's thoughts on the current problem(s)?
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What are your goals for treatment? Expectations for change?
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Under what circumstances would you rehome this dog?
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Under what circumstances would you euthanize this dog?
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Any final thoughts, concerns, or topics you would like to discuss?
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