Canine Behavior Questionnaire
Dr. Stacy Zuverink, DVM, ACVB Resident
CLIENT INFORMATION
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary veterinary clinic
Veterinarian's name
Clinic phone number
PET INFORMATION
Name
Breed
Date of birth
Sex
Male
Female
Neutered/Spayed
If neutered/spayed, at what age?
Approximate weight
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Age of pet when you got them
Date obtained
Where did you get your pet from?
Reason for obtaining your pet
Was your pet owned by anyone before you? If yes, please describe
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CURRENT CONCERNS
Please describe what you consider to be your pet's main behavioral problem. Be as specific as possible, including what happens, when it happens, when the behavior started, where it happens, who's involved, how often it happens, etc. Please describe the most recent two or three incidents of this behavior, including dates, locations, and as much other specific detail as possible.
Please describe anything you've tried to correct the problem (supplements, medication, training, routine changes, etc.) and what the outcome was.
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Pet's Daily Routine
Where does your pet sleep?
Where does your pet stay when nobody is home?
Is your pet crate trained?
Yes
No
How does your pet react to a crate or other confinement?
What does your pet do when you prepare to leave the house?
Has your pet every shown problematic behaviors when alone? (Destruction, elimination, vocalization, panting, salivation, etc.)
Where does your pet go outside?
How many times a day does your pet urinate? Defecate?
Do you have specific exercise routines for your pet?
Does your pet play with family members or other pets?
What are your pet's favorite games to play or toys to play with?
Does your pet ever go to daycare or boarding facilities?
Yes
No
How does your pet do in the car?
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Training History
Did your pet ever attend socialization groups or training classes?
Yes
No
Please describe any classes attended, including where, age of pet at the time, training methods used, things taught, etc.
What is your most commonly used method of training?
Please list all cues/tricks that your pet can reliably perform
How does your pet reach on leash/do on walks?
Does your pet seem more obedient in certain places or with certain people?
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Reactivity
Please describe how your pet reacts in the following situations, which as much detail as possible
Familiar people approaching
Children approaching
Unfamiliar people approaching at home
Unfamiliar people approaching away from home
Familiar dogs
Unfamiliar dogs at home
Unfamiliar dogs away from home
When approached while eating
When approached while playing with a toy
To the doorbell or a knock on the door
To thunder, fireworks, or other loud noises
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Aggression
Please describe, if applicable, your pet's behavior in the following situations, with as much detail as possible
Has your pet every been aggressive or threatening to the family?
Yes
No
Has your pet ever been aggressive or threatening to other household pets?
Yes
No
Has your pet ever been aggressive to unfamiliar people?
Yes
No
Has your pet ever been aggressive to unfamiliar animals?
Yes
No
Does aggression change depending on if your pet is on or off leash, or if the other animal is?
Has your pet ever bit a person?
Yes
No
If yes, did the bite break the skin and was medical treatment necessary?
Yes
No
Describe the event in detail
Has your pet ever bit another animal?
Yes
No
If yes, did the bite break the skin and was medical treatment necessary?
Yes
No
Describe the event in detail
Is your pet every aggressive in any other situations or circumstances?
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Pet's Medical History
Date of last veterinary visit
Please describe any previous, current, or chronic medical problems
Is your pet up to date on vaccines?
Yes
No
Is your pet on heartworm and flea/tick medication? If so, what kind(s) and for what portion of the year?
Date of last fecal test
Has your pet had any blood work performed? If yes, please provide copies of at least the most recent tests
Yes
No
Has your pet ever received medication or supplements for behavior issues? If yes, please list medication/supplement name and dosage below.
Yes
No
Type a question
Medication/Supplement Name
Strength (mg)
Dose given and frequency
Any thoughts?
1.
2.
3.
Please list all current medications and/or supplements your pet receives (behavior and non-behavior-related)
Medication/Supplement Name
Strength (mg)
Dose given and frequency
When was it started?
Purpose for giving?
1.
2.
3.
4.
5.
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If there is any other information you feel is relevant, please provide it here
What are your goals and expectations for your pet's behavior problem?
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