Questionnaire - Dogs
Please take the time to fill out this questionnaire by answering as many questions as you can and as honestly as possible. Information provided on this questionnaire is confidential, however I would like to be able to discuss the treatment plan with your veterinarian for better long-term care of your pet. Please indicate if you would not like me to discuss the treatment plan for your dog with your veterinarian when you are called to arrange a time for the consultation.

After the questionnaire is received and examined, you will receive a call to arrange a time for the consultation. The consultation takes about 2-3 hours and will include assessment of the environment and recommendations on how the environment in which your dog lives can be arranged to aid progress towards our goals.

Behaviour modification is often an important component of therapy. You will receive a demonstration during the consultation on how this can be achieved to improve your dog's wellbeing and ability to cope in situations with a behaviour that is more desirable to you. Please only allow your dog a small meal the morning of the consultation and do not feed him/her for the 6 hours prior to consultation. If you have a morning appointment, please remove access to food the evening prior to the consultation. It is important to have some of your dog's favourite treats and also his/her favourite toys available for the consultation but please keep them hidden away.

Video footage of your pets behaviour can be highly beneficial but please do not take video footage if it is likely to encourage any aggression.

I look forward to helping your dog with the problem that is affecting his/her wellbeing and causing you concern.

Sincerely,
Dr Sally Nixon BVSc MANZCVS (behaviour medicine)

Client Information
Name *
Your answer
Address *
Your answer
Postal Address (if different from residential address)
Your answer
Email address *
Your answer
Contact telephone number *
Your answer
Veterinary clinic where your animal is usually treated *
Your answer
How did you find out about this service? *
Your answer
Patient Information
Dog's name *
Your answer
Age / Date of Birth
This can be an approximate. Please indicate if you do not know.
Your answer
Breed
Your answer
Colour
Your answer
Gender *
Age at desexing
Your answer
Your dog's weight (kg)
Your answer
What are your dog's 3 favourite treats? *
Please answer as best you can
Your answer
What are your dog's 3 favourite toys? *
Please answer as best you can
Your answer
Medical History
List any major injuries / disease / trauma that your dog may have suffered and an estimate of when it occurred:
Your answer
List any ongoing or recurrent illness:
Your answer
List any recent trauma or illness:
Your answer
List any medications your dog is currently on:
Please list the medication and its concentration, the dosage and frequency of dosing and for how long your dog has been on this medication
Your answer
List any medications your dog has received for its behaviour:
Please list the medication and its concentration, the dosage and frequency of dosing, for how long your dog has been on this medication and for how long your dog has been off the medication if it has been discontinued.
Your answer
Please describe if there was any response from your dog to the medications given for the behaviour:
Please indication if the behaviour became worse, better or did not change. Also indicate if there was any apparent undesirable side-effect such as sedation.
Your answer
Information about the household environment
List the other people living in the household
Include their name, age, gender, length of residency within the house and their relationship to you
Your answer
Please give a brief description of a standard daily routine for each person in the household, including any interactions with the patient and/or other pets:
Your answer
Do you have any other pets in the house
Other pets in the household
Include their name, age, gender (including neutering status), species or breed, and the age when they were acquired
Your answer
Please describe briefly the relationship you perceive between each pet and the patient
Your answer
Information about your dog's history and lifestyle
When did you acquire the patient?
Your answer
From where did you acquire your dog (eg. shelter/petshop/breeder/friend)?
Your answer
If your dog had previous owners, please briefly state any reason you know of as to why he/she was given up for adoption?
Your answer
If you know any details regarding your dog's parents, littermates or other siblings, did they also have issues with problem behaviour?
Did your dog go to puppy socialisation classes when less than 12 weeks old?
Briefly state your reason for having a dog
Your answer
Why did you choose this breed of dog?
Your answer
Why did you choose this individual dog?
Your answer
For how long is your dog outdoors each day?
Your answer
If your dog has an exercise routine, please briefly describe
Your answer
Please briefly describe your dog's sleeping patterns and where he/she sleeps
Your answer
Please briefly describe the feeding patterns of your dog and what he/she eats at those times
Your answer
Where does your dog like to be when you are at home?
Your answer
Training
Has your dog been to any formal training?
From whom has your dog received formal training (if applicable)?
Your answer
What training techniques have been used in the past on your dog?
What training techniques are currently on your dog?
To which of the following cues can your dog respond correctly?
To which of the following cues can your dog respond only sometimes?
To which of the following cues can your dog respond rarely or never?
How does you dog respond to formal group training (if applicable)?
Please mark all that apply
How does your dog respond to his/her trainer (if applicable)?
Please mark all that apply
Information about the behaviour problem
What is the primary reason for seeking behaviour consultation?
Your answer
In what year or what age (approximately) was your dog when you first noticed the primary behaviour problem?
Your answer
Are there any other behaviour problems that you may wish to address with behaviour work-up?
Your answer
Have you tried any methods to correct the behaviour problems?
Please briefly list any methods tried and if the behaviour seemed better / worse / no change:
Your answer
Please describe 3 significant or typical examples of when the primary behaviour problem was exhibited
Include only: what your dog did, where it occurred, any people or animals at which the behaviour seemed directed, and briefly describe the response of people and other animals to the behaviour of the patient. Do not spend too much time with details. We can discuss any details further in the consultation.
Your answer
Was there any event that appeared to coincide with the onset of the primary behaviour problem?
If the first instance of the primary behaviour problem appeared to be triggered by an event, please give brief details of what occurred:
Your answer
Has the primary behaviour problem
Regarding any change in intensity of the behaviour, over what time period do you estimate the change has occurred?
Your answer
Regarding any change in frequency of the behaviour, over what time period do you estimate the change has occurred?
Your answer
Is you your dog's behaviour more unpredictable than it used to be
How often does the primary behaviour problem occur?
You can check more than one box
Do you find it difficult to pinpoint any pattern as to when the behaviour would occur?
You may feel that the behaviour occurs in many types of situations, making it difficult to predict when the behaviour will occur
If the primary behaviour problem most commonly occurs in a specific situation, how often in that specific situation can you predict that it may occur?
How does your dog react to familiar (known) visitors when they come to your home?
Please mark multiple boxes if applicable
How does your dog react to visitors with whom he/she is unfamiliar when they come to your home?
Please mark multiple boxes if applicable
In the event of loud noises or storms, does your dog show the following behaviours?
Please mark those that apply
Does your dog perform any of the following behaviours?
Please mark all that apply
If your dog performs any of the above behaviours, please indicate below if there are any situations where they will predictably occur:
For example, only when there is a storm or only when there is a particular visitor
Your answer
How does your dog react to familiar (known) dogs?
Please mark the most likely response
How does your dog react to unfamiliar dogs (dogs that your dog rarely meets)?
Please mark the most likely response
How does your dog react to human friends with whom he/she is familiar when away from the home environment?
Please mark the most likely response
If your dog is aggressive or vocal with other dogs nearby, is this generally worse when on leash?
How does your dog react to children?
Please mark the most likely response
How does your dog react to unfamiliar people when away from the home environment?
Please mark the most likely response
How does your dog react to the groomer?
Please mark the most likely response
How does your dog react to the veterinarian?
Please mark the most likely response
How serious do the other members of the household find the problem?
In 1-2 sentences, please state your ultimate goal with therapy
Please write what it is you would most like to achieve
Your answer
What options have you considered if your ultimate goal cannot be achieved?
Aggression
If your dog does not have a problem with aggression, you are finished.
Is there a specific person or animal to whom the aggression is directed?
Your answer
Please indicate the type/s of aggression shown:
On average, how often does your dog show the aggressive response indicated above?
Your answer
If not directed at a specific person or animals, is the aggression directed at:
How often has your dog bitten to leave a single puncture or tear to another dog?
Your answer
How often has your dog bitten to leave a single puncture or tear to a person?
Your answer
How often has your dog grasped and shaken or given multiple bites to another dog?
Your answer
How often has your dog grasped and shaken or given multiple bites to a person or part of a person?
Your answer
Has your dog every caused major injury to another dog?
Major injury is any injury that required the owner of the recipient to seek veterinary intervention for their dog
Has your dog every caused major injury to a person?
Major injury is any injury that required the recipient to seek medical intervention
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