Case Review - Canine Behavioral History

Canine History Form for Case Review

This document can take 20-30 minutes to complete. Be sure to click the "Submit" button at the end to finalize your submission.
Overview
Individual completing this form. *

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Pet's name*
Pet's approximate age or date-of-birth, sex, spay/neuter status, breed or breed mixture, & most recent weight. *
Ex: 2 year old, neutered male, Pembroke Corgi, 29 lbs.
Photograph of pet*

Cancelof
Veterinary Clinic, Doctor, and Telephone Number*
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?*

BreederShelterRescueFriend or family memberOther
What is the pet's history prior to acquisition?*
Approximate date and age of acquisition?*
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?*
Briefly describe your pet's personality. *
Describe the problem(s) you are currently having. *
When did this start?*
What has been tried to correct the problem?*
Do you suspect any cause?*
Describe the last three incidents or episodes. *
Describe the dog's body posture during these episodes. *
What was your (or your family's) response to these episodes?*
What was your dog's reaction to your response?*
If there were aggressive behaviors, what was the result to the victim? (Check all that apply)*

Not applicableNo contact, just posturingBruiseScratchShallow puncture (Less than 0.5 inches deep)Deep puncture (Greater than 0.5 inches deep)TearingRequired medical treatmentOther
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. *
Medical History
What do you feed your dog? Please provide name/formula, quantity fed, frequency of feeding, & crude protein percentage on the bag. *
Ex: Science Diet Adult Small Bites - 1/3 cup twice daily.
How would you describe your dog's appetite? Select all that apply.*

Poor, very pickyGood, eats normalVoracious, always eatingConsistentSporadic

Please provide information about any routine products, medications, or supplements: *

Rows	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.*

CoughingSneezing (excessive)Eye dischargeNose dischargeVomiting or regurgitationDiarrhea or soft stoolLameness or limpingChanges in activity levelSeizuresSurgery (besides spay/neuter, if applicable)None of the aboveOther
Does your pet have a relationship with any of the following veterinary specialists?*

Internal MedicineSurgery/OrthopedicsRehabilitation/Physical TherapistChiropractor and/or AcupuncturistOphthamologistDermatologistOncologistBehavioristOtherNot 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. *

Rows	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.

Rows	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?*

Single Family HomeTownhouseCondo/ApartmentOther
How would you describe the energy in your home?*

Quiet, slow, routine orientedModerate activity, some sporadic changesHigh activity, lots of coming & going, noisy
Have you owned a dog in your adult life prior to this one?*

YesNo
How do you feed your dog?*

Out of a bowlFeeder toysPuzzle toysAs part of trainingOther
Where does your dog eat in relation to other pets in the household?
Do you need to be present for your dog to eat?*

YesNoSometimes
Is your dog protective of their food?*

YesNoWith family membersWith childrenWith strangersWith housematesWith visiting pets
Where does your dog spend most of their day?*
Where does your dog sleep at night?*
In a 24 hour period, how much does your dog sleep?*
How does your dog ask to go outside?*
How many times does your dog go outside per day?*
How long does you dog like to be outside?*
Do you have a yard? If yes, check all that apply:*

YesNoUnfenced - goes out off leashUnfenced - goes out on leash/tetherElectric fence with associated collarFenced, but can get through, over, or aroundSee through fencing (picket, wire, etc.)Privacy fencingSmall (Less than 0.25 acres)Medium (0.25 - 1 acre)Large (Greater than 1 acre)
Does your dog run and bark at the fenceline?*

YesNoNot applicableChases peopleChases dogsChases wildlifeChases moving objects
What type of physical exercise does your dog get on a regular basis?*

None1-3 sessions per day4-6 sessions per day>6 sessions per dayShort walk (0.25 - 1 mile)Long walk (> 1 mile)Jogging/RunningTreadmillFetchWrestlingTug-of-war playAgilityOther
Is your dog playful?*

YesNoSometimes
Is your dog affectionate or cuddly?*

YesNoSometimes
Does your dog like to chew?*

YesNoSometimes
Do they ever destroy their toys?*

NoYesSometimes
Any inappropriate chewing?*

YesNoSometimes
Any additional details around play, chewing, etc?
Where does your dog stay when no one (no people) is home?*
What does your dog do as you prepare to leave?*
Do you record or monitor your pet when they are home alone?*

YesNoSometimes
What is the average length of time your pet might be left home alone?*
Does your dog exhibit any of the following behaviors as you are preparing to leave or once you are gone?*

Pacing and/or panting for extended periods of timeVocalization including whining, crying, barking, howlingDestruction of doors, windows, or wallsChewing and destroying inappropriate objectsUrination and/or defecationExcessive droolingVomitingNone of the above
Training & Learning History
How would you describe your dog's ability to learn?*

PoorAverageExcellent
Is there any specific time devoted to training each day?*

YesNo
Have you ever attended any professional, group classes?*

YesNo
Have you ever worked with a private trainer?*

YesNo
Has your dog ever gone to a board and train facility?*

YesNo
Have you ever met with a veterinary behaviorist, animal behaviorist, or other behavior consultant?*

YesNo
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?*

ComeSitDownStandLeave itDrop itOffWait or stayPlace or settleNoneOther
Does your dog pull on the leash?*

Yes - AlwaysYes - SometimesYes - RarelyNo - Use trainer collar(s)No - Never pullsNo - We don't go for walks
How do you correct your dog when they misbehave?*
What training aids are you CURRENTLY using?*

TreatsFlat collarMartingale collarBody harnessHead collar/Halti/Gentle LeaderSlip collar/chock chainMetal prong/pinch collarPlastic prong/pinch collarVibration collarVibration/electronic/stim collar - underground fence onlyVibration/electronic/stim collar - remote operatedNone
What training aids have you used PREVIOUSLY?*

TreatsFlat collarMartingale collarBody harnessHead collar/Halti/Gentle LeaderSlip collar/chock chainMetal prong/pinch collarPlastic prong/pinch collarVibration collarVibration/electronic/stim collar - underground fence onlyVibration/electronic/stim collar - remote operatedNone
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.)

Rows	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. *

Rows	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?*

YesNoUrinationDefecationWhen home aloneWhen family is home
Any distress associated noises, storms, or fireworks?*

YesNoSometimesThunderstormsFireworksOther
Does your dog demonstrate any inappropriate sexual behavior?*

YesNo
Is your dog protective of any part(s) of their body?*

YesNo
Does your dog ever demonstrate any of the following behaviors?*

Chases lights or reflectionsChases shadowsChases their tail/spinsSuckles on blanketsExcessively lick themselvesExcessively lick othersExcessively lick other surfacesCause injury to themselves from licking or chewingMasturbateAttack the TVNone 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.*

12345678910
What is the family's thoughts on the current problem(s)?*
What are your goals for treatment? Expectations for change?*
Under what circumstances would you rehome this dog?*
Under what circumstances would you euthanize this dog?*
Any final thoughts, concerns, or topics you would like to discuss?
Should be Empty:

Canine History Form for Case Review

Overview

Consent to Use Medical Information for Professional Development

Acquisition & Early History

Medical History

Household & Daily Life

Training & Learning History

Miscellaneous Behaviors

Perspective & Expectations