Jones Animal Behavior: Canine History

Jones Animal Behavior

Canine Behavior History Form
Who may I thank for referring you to me?
Owner Information
Primary Owner/Contact Name*

First NameLast Name
Email
example@example.com
Phone Number*

Area CodePhone Number
Other Legal Owner(s)
Other Email
example@example.com
Other Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip
House color & parking instructions (for home visits)
Dog Information
Primary or most concerning dog
Dog Name*
Breed(s) *
Age*
Sex*

Spayed FemaleIntact FemaleNeutered MaleIntact Male
Where did you get this pet?*
What do you know about this pet's history?*
How long has this pet lived with you?*
Family Make Up
HUMANS (living with, frequently visiting, etc.)
PETS (living with, frequently visiting, but not directly involved in behaviors)
Are any other pets DIRECTLY involved in the concerning behaviors?*

NoYes, 1 other petYes, 2-3 other petsYes, 4-6 other pets
2nd pet directly involved
3rd pet directly involved
4th pet directly involved
5th pet directly involved
6th pet directly involved
The Behaviors
Describe the most concerning behavior you wish to address *
Describe the 2nd most concerning behavior you wish to address, if any
Describe the 3rd most concerning behavior you wish to address
Describe the 4th most concerning behavior you wish to address
Provide any additional behaviors and/or information.
Training History
How do you typically correct unwanted/bad behavior?

Physical (Spanking, nose tap, etc)Verbal (Scold, No!, AhhAhh!, Tsst!, etc)Noise (Squirt bottle, penny can, clap hands, etc)Leash jerk / popElectronic collarI don'tOther
How do you typically reward good behavior?

Affection (praise, petting, etc.)TreatsI don'tOther
Please list any trainers you have worked with in the past.
What have you specifically tried to resolve the problems in the past?*
How did the behaviors change in response to what you described above?

Got worseGot betterNo changeUncertainOther
Health, Nutrition, Exercise
How many hrs/day is dog alone on average?
Describe type, amount, and intensity of exercise
Name of your vet clinic and the vet you prefer (if any).*
Did your vet give you any recommendations for your concerns?*
Date of most recent exam and notable comments*
Proof of rabies vaccination (file must be under 1024KB. If file doesn't upload, clear this field to allow form submission)

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Any other relevant records

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List any current, recent, or past injuries or illnesses*
List any medications, supplements, etc. *
List any food or environmental sensitive or allergies*
What brand/kind of food does your dog eat?
Describe feeding routine (check all that apply)

Feed at scheduled times, finishes right awayFill bowl at scheduled times, grazes throughout dayFood is always availableDry kibbleCannedRaw or homemadeScraps or left over people foodOther
Do you have pet insurance?

YesNo
House Soiling Information
Is your dog having house soiling issues?*

Never (unless rare circumstances like illness)Yes or sometimes
WHERE is your dog eliminating?

In the crateOn the hardwoodsOn tile or linoliumOn carpetOn laundry, blankets, throw rugs etc.On furnitureOther
WHAT is your pet doing?

Hiding from meLifting leg to urinateEating fecesChewing on or dragging bumModerate to large urine puddlesTiny to small urine puddlesDrops of urineLarger than expected bowel movementsParticularly soft bowel movements
Aggression Information
Has this dog shown aggression (growl, lunge, bite, snap, etc.)?*

NoYes
Has this dog ever?*

Bitten accidentally (not playfully)Bitten intentionallyGrowled (not playfully)Snapped without contactCaused bruising or skin dents with teethScratched skin or some blood from tooth contactShallow puncture(s)Deep puncture(s)Multiple bites in one incidentMedical attention required for victimOther
Has this dog ever shown aggression when*

Being picked up (ex: for affection, for bathing, to be moved, etc)Being pushed/nudged (ex: to move over on couch, accidentally during sleep, to get off bed, etc.)Having anything taken out of their mouth (ex: toy, chew, "stolen" or "found" item you don't want them to have, etc.)Body handling (ex: grooming, cleaning/medicating ears, pulling something out of fur, inspecting feet, trimming nails etc.)Other
Who has aggression been directed toward?*

An adultA childA catA dog"Family" that lives/lived in home"Friend" of the dog that doesn't live withStrangerOther
Has this dog ever shown aggression when*

Being picked up (ex: for affection, to be moved, etc)Being pushed/nudged (ex: to move over on couch, accidentally during sleep, to get off bed, etc.)Body handling (ex: grooming, cleaning/medicating ears, pulling something out of fur, inspecting feet, trimming nails etc.)Taking something away (ex: food, chew, "stolen" or "dangerous" item you don't want them to have)Being cornered or caughtWhen stressed, nervous, anxious, afraid, etc.Having leash, muzzle, jacket, etc, put on.Other
Describe most severe instances:
Provide any additional behaviors and/or information.
Where is the aggression occurring?*

Inside homeAt the doorThrough home windows/doorsOutside on propertyAt fence lineOff propertyOn leashWhen off leashWhen in the carAway from homeAt the vet, groomer, etc.Other
Mentee Shadowing

Would you allow a mentee to shadow me in your appointment?

(Note: mentee will not give advice, participate, nor touch your pet unless instructed to do so by me and with your permission).
Yes, I would allow someone to shadowNo, I prefer no one else attend
Agreement, Waiver & Release

Please review the following and check below to accept and proceed. (after reviewing, do not close the window, click "back" to return to this form).
I have read and agree to the above

I have read and agree to the above.
Should be Empty: