Lyndale Animal Hospital

(612) 872-4674

Canine Behavior Consultation Questionnaire

We want to make the best possible use of your appointment time. Therefore, we would like to gather as much information as possible prior to your arrival at Lyndale Animal Hospital.

Please complete the five-section questionnaire as accurately as you can. Make sure you email it to lyndaleanimalhospital@earthlink, or fax it to (612) 872-4674 (Attn: Michelle) before the consultation.

Section 1: General Information
Name of the owner: ______________________________ Preferred contact method: email or phone

Name of dog: _________________________________

Breed of dog: _________________________________

Date of birth: ___/___/______

Sex: O female O male

O spayed O neutered

Source: O breeder O shelter/rescue

O friends O other: ___________________________

Age of dog when acquired: ___________

Number of previous owners: ___________

Pre adoption history: ___________________________________________________________________

Food (brand or composition):____________________________________________________________

Frequency of meals O once daily O twice daily O free choice

Does your animal have any diet restrictions? __________________________________________________

Exercise: _________ times / day for _______ minutes

O on leash O off leash O back yard O park O walk O playing with dogs

O special exercise (e.g. weekends): _________________________________________________________

Housing : O apartment/condominium O duplex O single family home

Yard fencing: O none O electric/invisible O chain link / wood: ___ ft high

Location: O city O suburb O rural/country

Confinement: O kenneled (____ h/day) O crated ( _____ h/day)

O confined in one or more rooms _____________________________________

Family members:

Name Age

___________________________________ __________

Section 1 continued

Other pets in the household:

Dog: _______ __________ __________ __________

Cat: _______ __________ __________ __________

Others: _______ __________ __________ __________

Has your dog ever bitten anyone under any circumstances? ____________________________________

If yes: How many bites have not broken skin? ________________

How many bites have broken skin? ___________________

Please describe the most severe injury that has resulted from a bite:

Has there ever been a complaint (formal or informal) made against this animal with a law enforcement or animal control agency for any reason? ____________.

If yes, when, where and for what reason?

Training classes and age of dog when s/he was enrolled
O puppy class Age: ___ Trainer/school: __________________

O beginner obedience Age: ___ Trainer/school: __________________

O advanced obedience Age: ___ Trainer/school: __________________

O agility Age: ___ Trainer/school: __________________

O fly ball Age: ___ Trainer/school: __________________

O ______________ Age: ___ Trainer/school: __________________

Collars/leashes used: O flat buckle collar O choke collar

O prong collar O harness around chest

O 4 or 6ft leash O retractable leash

O Gentle leader ® O Halti ®

O electric collar, remote control O electric bark collar

O citronella collar, remote control O citronella bark collar

ALL existing medical conditions (e.g. Thyroid disease, Hip dysplasia, Allergies, Coughing, Vomiting)

List all medications and food supplements the dog receives currently (since when, brand name and dosage):

Section 2: Problem

Primary complaint: ____________________________________________________________________

How serious is the problem for you on a scale of 1to 10 (1 = we want to learn about this problem, but would never consider to adopt/euthanize the dog; 10 = the problem behavior must stop to enable us to live with the dog). Circle:

1 2 3 4 5 6 7 8 9 10

Onset of the problem was at ________________ months / years of age.

Since the beginning the problem:
O is seem more frequently O occurs for longer periods of time

O is unchanged O _______________________________________________________

2nd complaint: _______________________________________________________________________

1 2 3 4 5 6 7 8 9 10

Onset of the problem was at ________________ months / years of age.

Since the beginning the problem:
O is seem more frequently O occurs for longer periods of time

O is unchanged O _______________________________________________________

3rd complaint: _______________________________________________________________________

1 2 3 4 5 6 7 8 9 10

Onset of the problem was at ________________ months / years of age.

Since the beginning the problem:
O is seem more frequently O occurs for longer periods of time

O is unchanged O _______________________________________________________

Please describe the last three events of the primary complaint in detail:

Section 2 continued

What else has been tried so far to improve the situation (please describe briefly):

Did you consult with others previously (please name the person, if possible)

O help of a trainer: _____________________________

O help of a behaviorist: _____________________________

O help of a veterinarian: _____________________________

O others: _____________________________

Please list the recommendations that you received:

How do you react if the dog behaves in an undesired way?

O Scolding O Electric collar

O Verbal reprimand O Leash correction (pull on leash)

O Slap with e.g. hand or paper O Slap with another object
O No punishment O ‘Time out’ (taken outside or into a crate)

O ‘Alpha-roll’(rolling on back) O ‘Growl’, ‘bark’, or bite the dog

O Scruffing (hold skin of neck) O Stare down (maintain eye contact)

O Ignore behavior O other: _________________

What behavior is the dog reprimanded for and how often?

____________________________ ______________ (times per day, week, or month)

Section 3: Behavioral Questions

Never Rarely Sometimes Often Always Not Applicable

1 2 3 4 5 NA

Barks and/or lunges when away from home when on leash and an unfamiliar dog approaches. 1 2 3 4 5 NA
Barks and/or lunges when away from home when off leash and an unfamiliar dog approaches. 1 2 3 4 5 NA
Initiates fights with unfamiliar male dogs. 1 2 3 4 5 NA
Initiates fights with unfamiliar female dogs. 1 2 3 4 5 NA
Has bitten (broken skin) of another dog (not living in the same household). 1 2 3 4 5 NA
Has bitten (broken skin) of another dog (living in the same household). 1 2 3 4 5 NA
The dog is seen mounting other dogs? 1 2 3 4 5 NA
Ignores or is aloof to an approaching unfamiliar male dog. 1 2 3 4 5 NA
Ignores or is aloof to an approaching unfamiliar female dog. 1 2 3 4 5 NA
Crouches and/or rolls over and/or urinates when approached by an unfamiliar dog. 1 2 3 4 5 NA
Tucks tail between legs and/or flattens ears when approached by an unfamiliar dog. 1 2 3 4 5 NA
Retreats when threatened by another dog. 1 2 3 4 5 NA
Does the dog refuse to sit on command? 1 2 3 4 5 NA
Does the dog refuse to lie down on command? 1 2 3 4 5 NA
Does the dog refuse to stay in a place on command? 1 2 3 4 5 NA
Does the dog refuse to come to you on command when he/she is in the yard? 1 2 3 4 5 NA
Does the dog refuse to come to you on command when let off-leash in a public area? 1 2 3 4 5 NA
Does your dog paw, push, or mouth your hand or leg to be petted? 1 2 3 4 5 NA
Does your dog jump up on you when greeted? 1 2 3 4 5 NA
Does your dog appear restless or hyperactive at home? 1 2 3 4 5 NA
Does the dog attempt to mount family member’s legs? 1 2 3 4 5 NA
Is the dog aloof around family members? 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites when you approach food/toy or try to take food/toy away. 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites when hugged, pulled, or restrained by owner. 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites when approached while sleeping/resting. 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites when touched / pushed when sleeping/resting. 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites when petted by a familiar person 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites when someone tries to take away an item the dog ‘stole’. 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites when specific body parts are touched/toweled/examined. 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites when reprimanded or punished. 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites for no apparent reason. 1 2 3 4 5 NA
Growls/bares teeth/snaps/bites at familiar persons when _______________________. 1 2 3 4 5 NA
Has bitten (broken skin) of family member or another person he/she is familiar with. 1 2 3 4 5 NA
Name family members to whom the dog displays aggressive behavior: _______________
Tucks tail between legs and/or flattens ears when approached by an unfamiliar person. 1 2 3 4 5 NA
Crouches and/or rolls over and/or urinates when approached by an unfamiliar person. 1 2 3 4 5 NA
Growls and/or lunges when away from home and an unfamiliar person approaches. 1 2 3 4 5 NA
Growls and/or lunges when at home and an unfamiliar person approaches. 1 2 3 4 5 NA
The dog is aggressive to some persons (children, men, people in uniform, etc.) __________ 1 2 3 4 5 NA
Has bitten (broken skin) an unfamiliar visitor at home/yard/cabin. 1 2 3 4 5 NA
The dog has bitten (broken skin) an unfamiliar person in neutral surroundings (not home). 1 2 3 4 5 NA
Acts anxiously when outside (on or off leash) when it is dark than during daylight. 1 2 3 4 5 NA
Appears fearful when introduced to new and unfamiliar places and objects. 1 2 3 4 5 NA
Shakes, trembles, tucks tail between legs, pants and paces or tries to hide when hearing
loud noises such as thunder or firecrackers. 1 2 3 4 5 NA
In your home, follows you or family members from room to room. 1 2 3 4 5 NA
The dog doesn’t eat when left alone. 1 2 3 4 5 NA
Does your dog bark, whine, or howl when left alone at home? 1 2 3 4 5 NA
Does your dog bark, whine, or howl when left alone in the car? 1 2 3 4 5 NA
Destroys household objects by chewing, digging or scratching when left alone. 1 2 3 4 5 NA
Destroys household object by chewing, digging or scratching when a person is present. 1 2 3 4 5 NA
If confined, (in a room, house or yard) tries to escape by digging or scratching. 1 2 3 4 5 NA
Has injured himself while trying to escape (get out of) a crate or confinement? 1 2 3 4 5 NA
Pants, paces or salivates (any or all) when you are getting ready to leave your home. 1 2 3 4 5 NA
Whines or tries to hide when you are getting ready to leave your home. 1 2 3 4 5 NA
Does your dog walk, run, or pace compulsively? 1 2 3 4 5 NA
Does your dog lick himself/herself excessively? 1 2 3 4 5 NA
Does your dog snap into the air (catch imaginary flies)? 1 2 3 4 5 NA
The dog urinates in the home when left alone. 1 2 3 4 5 NA
The dog defecates in the home when left alone. 1 2 3 4 5 NA
The dog urinates in the home when confined. 1 2 3 4 5 NA
The dog defecates in the home when confined. 1 2 3 4 5 NA
The dog urinates in the home when owners are at home. 1 2 3 4 5 NA
The dog defecates in the home when owners are at home. 1 2 3 4 5 NA
The dog releases small quantities of urine when he/she greets a person/dog. 1 2 3 4 5 NA
The dog fails to signals when he/she wants to be let outside 1 2 3 4 5 NA
The dog barks at neighbors’ dogs or passersby when they are on / passing your property. 1 2 3 4 5 NA
Barks at moving objects such as bicycles, children running, or joggers when he is in the yard? 1 2 3 4 5 NA
Barks and or lunges at people on roller blades, bikes, or joggers during walks. 1 2 3 4 5 NA
Barks and or lunges at children on walks. 1 2 3 4 5 NA
Chases cars or trucks? 1 2 3 4 5 NA

The dog appears confused or disoriented at times. 1 2 3 4 5 NA
The dog appears restless at night and sleep more during the day. 1 2 3 4 5 NA
The dog is showing less interaction with the family than in the past. 1 2 3 4 5 NA
The dog fails to recognize persons or places he/she was familiar with? 1 2 3 4 5 NA
The dog ‘forgot’ tricks he knew in the past. 1 2 3 4 5 NA
The dog is a picky eater. 1 2 3 4 5 NA
The finishes his/her dish immediately. 1 2 3 4 5 NA
The dog will eat items that are not meant for consumption (rocks, plastic, socks, etc.). 1 2 3 4 5 NA
The dog will eat his/her own feces or the feces of another dog. 1 2 3 4 5 NA

Strongly strongly
disagree unsure agree

1 2 3 4 5 6 7

I like watching my dog enjoy his/her food. 1 2 3 4 5 6 7
This dog means more to me than any of my friends. 1 2 3 4 5 6 7
I would bring another pet into my home. 1 2 3 4 5 6 7
Having dogs is not a waste of money. 1 2 3 4 5 6 7
My dog adds happiness to my life. 1 2 3 4 5 6 7
I spend time every day playing with my dog. 1 2 3 4 5 6 7
I know which feeling my dog is trying to express. 1 2 3 4 5 6 7
The world would be a better place if people spent
as much time with their dog as they do with other humans. 1 2 3 4 5 6 7
I like to hand feed my dog. 1 2 3 4 5 6 7
I love pets. 1 2 3 4 5 6 7
Pets are fun and worth the expense and trouble. 1 2 3 4 5 6 7
I frequently talk to my dog. 1 2 3 4 5 6 7
I love animals. 1 2 3 4 5 6 7
You should treat pets with as much respect as you
would treat human family members. 1 2 3 4 5 6 7
My dog is my best friend. 1 2 3 4 5 6 7
I like to have my dog sleep with me. 1 2 3 4 5 6 7
My dog eats at the table with me. 1 2 3 4 5 6 7
My dog understands me better than any human in my life. 1 2 3 4 5 6 7
I expect unconditional love from my dog. 1 2 3 4 5 6 7
Animals belong in the home as much as they do in the wild. 1 2 3 4 5 6 7

Answers for other members of the household to the above questions:

Name: __________________________________________________

1.____ 2.____ 3.____ 4.____ 5.____ 6.____ 7. ____ 8.____ 9.____ 10.____ 11.____ 12.____ 13.____ 14.____

15.____ 16.____ 17.____ 18.____ 19.____ 20.____

Name: __________________________________________________

1.____ 2.____ 3.____ 4.____ 5.____ 6.____ 7. ____ 8.____ 9.____ 10.____ 11.____ 12.____ 13.____ 14.____

15.____ 16.____ 17.____ 18.____ 19.____ 20.____

Name: __________________________________________________

1.____ 2.____ 3.____ 4.____ 5.____ 6.____ 7. ____ 8.____ 9.____ 10.____ 11.____ 12.____ 13.____ 14.____

15.____ 16.____ 17.____ 18.____ 19.____ 20.____

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Section 3: Behavioral Questions

Never Rarely Sometimes Often Always Not Applicable

Strongly stronglydisagree unsure agree

Strongly strongly
disagree unsure agree