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 Owner /Caregiver/Foster
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)

Primary Pet 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

Describe all HUMANS in this DOG'S life:*

	Name	Age	Pronouns	Relationship	Interaction Frequency
1
2
3
4

Describe all other ANIMALS in this DOG'S life (not directly involved in your behavior concerns):*

	Name	Age	Species	Breed	Relationship	Interaction Frequency
1
2
3
4

If any other pets are directly involved, describe below. If none, leave blank and skip to next section.*
Breifly describe the conflict:
If any other pets are directly involved, describe below*
Breifly describe the conflict:
If any other pets are directly involved, describe below*
Breifly describe the conflict:

The Behaviors

There are questions/details later in the form specific to house soiling and to aggression
Describe the most concerning behavior you wish to address, if any
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.

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 agreement and check below to accept and proceed

(Note: a copy of the agreement will be attached to the email you receive after submitting this history form).
Should be Empty: