Dogwood Canine Behavior and Health History Questionnaire
Please complete this form prior to your behavior appointment. Your detailed answers help us understand your dog’s background, environment, and current challenges so we can make the most of our time together.
Owner Information
Client Name
*
First Name
Last Name
Email address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Information
Pet’s Name
*
Pet’s Age or Date of Birth
*
Pet’s Gender
*
Female Intact
Female Spayed
Male Intact
Male Neutered
If applicable, date or age of spay/neuter
Pet’s Breed
*
Upload a picture of your pup to help us identify you when you arrive
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Care Veterinarian Information
Veterinarian Name
Clinic Name
Veterinarian Email Address
example@example.com
Veterinarian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Acquisition & Background
How did you acquire your dog?
*
Breeder
Rescue/Shelter
Stray
Other
Date acquired
Primary Reason for acquisition (companionship, service animal, working animal, show, etc.)
Do you know any prior history (before you acquired them)? If known, describe your dog’s interactions with people and/or other animals during their first year of life.
Household Environment
People living in the home
Other animals in the home
Type of home
Apartment
Condo
House
Other
Do you have a yard?
No
Yes
If yes, is it fenced?
Yes
No
Fence type
Primary Behavioral Concerns
What is the main behavior concern you would like help with?
*
When did this behavior first start?
Were there any changes in the household or routine around the time this behavior began? (e.g., move, new person or pet, schedule change, illness, stressors)
Please describe the THREE most recent incidents in detail (what happened, who was involved, where it occurred):
How would you describe your dog’s body posture or signals during these incidents? (e.g., stiff, frozen, cowering, growling, barking, tail position)
What was your reaction during these incidents?
How did your dog respond to your reaction?
If aggression occurred, what was the outcome?
No injury
Scratch
Bruise
Puncture
Tear
Other
Did the injury require medical attention?
No
Yes
If yes, please explain
How often does this behavior occur?
Daily
Weekly
Monthly
Rarely
Unpredictable
If house-soiling is a concern, does it occur when:
You are home
You are gone
Both
What have you tried so far to address this behavior (training methods, medications, etc)? Has anything helped or made it worse?
Any additional relevant details
Is there any legal action pending related to this behavior?
No
Yes
If yes, please explain
Feeding & Food-Related Behavior
Is feeding separate from or near other pets?
How is food provided?
Bowl
Puzzle/foraging
Combination
Do you need to be present for your dog to eat?
Yes
No
Does your dog show protectiveness around food?
No
Yes – toward people
Yes – toward other animals
Sleep
Where does your dog usually sleep?
Does your dog wake you at night?
No
Yes
If yes, please explain
Typical Daytime Routine
Where is your dog usually during the day?
Exercise and play (type, frequency, duration, favorite toys):
Training History
Has your dog attended professional training classes?
No
Yes
Where / with whom:
How would you rate your dog’s ability to learn?
Very easy
Average
Difficult
Cues your dog reliably knows:
Leash pulling a concern?
No
Yes
How do you typically correct your dog when they misbehave?
Training tools used (current or past):
Treats
Head halter
Body harness
Choke chain
Prong collar
Shock/vibration collar
Noise deterrents (penny can, chains)
None of the above
Other
Separation & Alone-Time Behavior
Is your dog crated when alone?
No
Yes
What does your dog do when you prepare to leave?
How long is your dog typically left alone?
Do you record your dog when you are gone?
No
Yes
Behaviors observed when home alone:
None
Urination in the house
Defecation in the house
Pacing or panting for long periods
Vocalization (barking/howling)
Excessive drooling/salivation
Destruction of household items
Refusal to eat
Other
Arrangements when you are out of town:
Aggression
Please check any situations where aggression has occurred. Please explain below.
Rows
Toward Primary Owner
Toward Other Adults
Toward Known Children
Toward Others
Handling/grooming
Petting/hugging
Disturbed while resting
Discipline
Taking food away
Taking objects away
Please explain:
Visitors & Novel Situations
Typical response to the following (e.g., Barks, hides, friendly, lunging, etc):
Rows
Inside the Home
Outside the Home
Frequent visitors
Occasional visitors
Unknown men
Unknown women
Unknown children
Unknown dog on leash
Unknown dog off leash
Crowds / busy areas
Trucks / buses / cars
Additional Concerns (check all that apply)
Travel-related behaviors
None
Avoids getting into car
Excessive drooling
Rapid breathing
Inability to settle
Vocalizing
Vomiting
Trembling
Hiding
Other
Repetitive behaviors
Chasing lights/shadows
Tail chasing
Snapping at air
Suckling on self or blankets
None
Other
Other behaviors
Protective of specific body areas
Excessive licking/chewing self
Excessive licking/chewing objects
Fearful or stressed at vet visits/grooming/handling
Storm sensitivity
Firework sensitivity
Sensitivity to loud noises
Mounting behavior
Additional notes or other concerns
Goals & Expectations
Your thoughts about the current problem
What changes are you hoping to see?
Your goals for treatment
Under what circumstances would you consider rehoming, relinquishment, or euthanasia?
What is ONE thing you absolutely LOVE about your dog?
Canine Health History Questionnaire
Referring Veterinarian
Has your dog seen any other specialty services (e.g., neurology, internal medicine, surgery, dermatology)? If yes, please list:
Medications
Current medications (Include all prescription medications, supplements, heartworm prevention, and flea/tick prevention.)
Has your dog ever had an adverse reaction to a medication?
No
Yes
If yes, please explain
List behavioral medications your dog has taken in the past (if known):
General Health History
Have you noticed any changes in your dog’s eating or drinking habits in the past year?
No
Yes
If yes, please explain
Has your dog experienced any of the following in the past year?
Coughing
Sneezing
Vomiting
Diarrhea
Lumps or bumps
Pain
Limping
Other
Has your dog ever had a seizure?
No
Yes
If yes, please explain
How would you describe your dog’s typical energy level?
Very low – does not enjoy walks or playtime; sleeps most of the day
Low – short walks and brief play periods, sleeps most of the time
Moderate – enjoys walks, has clear awake and rest periods, plays if engaged
Moderate-high – needs at least one 45-minute walk or play session daily; naps briefly
High – needs multiple runs or play sessions daily; struggles to rest during the day
Any other thoughts about your dog’s personality, energy, or engagement?
Gastrointestinal (GI) History
What brand/name of food is your dog fed and how much?
List any supplements or other over-the-counter products:
Any known or suspected food allergies?
Previous diets tried and any behavior or GI changes noted:
Appetite - Kibble intake
Good
Moderate
Poor
Appetite - Treat intake
Never
Picky
Likes most
Ravenous
Appetite - Human food intake
Never
Picky
Likes some
Likes most
LOVES
Licking behaviors (Check all that apply)
No excessive licking
Licks or chews furniture, carpet, or bedding
Licks or chews doors, walls, laminate, or hardwood
Excessively licks people
Excessively licks self
Non-food chewing or consumption (Check all that apply)
Does not eat non-food items
Eats small amounts of grass occasionally
Eats grass frequently but can be redirected
Eats grass frequently and is difficult to redirect
Has an intense fixation on eating grass
Consumes small parts of chews or bones
Consumes large parts of chews or bones
Consumes found or stolen objects
Does your dog eat their own or other animals' feces?
No
Yes
Any other licking, chewing, or eating behaviors not listed above?
Does your dog experience any vomiting or regurgitation?
No
Yes
If yes, please explain
Upper GI signs (Check all that apply)
Frequent swallowing
Difficulty swallowing
Gagging without vomiting
Excessive lip licking
Drooling
Lip smacking
Excessive burping
Other
Stool quality - Normal fecal consistency according to the Purina fecal score chart? Explain if needed.
1
2
3
4
5
6
7
Excessive flatulence?
No
Yes
Excessive belly sounds?
No
Yes
Anal gland issues?
No
Yes
Explain if needed
Skin and Ears
Excessive licking or scratching?
No
Yes
Brown saliva staining on feet?
No
Yes
History of ear infections?
No
Yes
Explain if needed
Pain and Mobility
Have you noticed any of the following? (Check all that apply)
Slowing down on walks
Limping after exercise
Slow to rise from lying down
Difficulty jumping onto furniture or into vehicles
Stiffness
Difficulty going up or down stairs
Difficulty chasing toys or objects
Difficulty running
Avoid being touched in a particular region of the body
Restlessness or difficulty sleeping at night
Has your dog been diagnosed with pain or arthritis?
No
Yes
Has your dog been prescribed pain medication?
No
Yes
Explain if needed
Consent and Agreement
Client Name (printed)
*
First Name
Last Name
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
How did you hear about us?
Primary Care Veterinarian
Trainer
Internet
Social Media
Submit Questionnaire
Submit Questionnaire
Should be Empty: