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
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.
Has your dog seen any other specialty services (e.g., neurology, internal medicine, surgery, dermatology)? If yes, please list:
Back
Next
Acquisition & Background
How did you acquire your dog?
*
Breeder
Rescue/Shelter
Stray
Other
Date acquired
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
Back
Next
Canine Health History Questionnaire
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):
Gastrointestinal (GI) History
What brand/name of food is your dog fed and how much?
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
List any other notable licking, chewing, or eating behaviors ( excessive licking people, grass eating, etc)
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
Anal gland issues?
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
Back
Next
Primary Behavioral Concerns
What is the main behavior concern you would like help with?
*
When did the behavior 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 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)
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
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
Back
Next
Feeding & Food-Related Behavior
How is food provided?
Bowl
Puzzle/foraging
Combination
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
Training History
Has your dog attended professional training classes?
No
Yes
Where / with whom:
Cues your dog reliably knows:
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
Back
Next
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?
Back
Next
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: