Canine Behavior History Form

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Email *

First and Last Name of Owners *

Date *

YYYY

Home Address *

Email and Cell Phone Number for each Owner *

Dog's Name, Age, Breed, Weight, and Gender *

Spayed and/or Neutered? *

Referred by?

List your primary care veterinarian, name of the clinic and town and date of last examination *

Date and age of dog at purchase/ adoption - indicate name of breeder or rescue *

Primary behavior problem with date of most recent incident *

Secondary behavior problem with date of most recent incident *

How long has primary the behavior problem been happening? *

How long has the secondary behavior been happening?

Ages and number of people living in the home, or who visit multiple times a week

List all the pets, breed and ages living in the home

List how often your dog goes out in the yard, on a walk or on a tie out for elimination and exercise daily

Please list all past injuries, surgeries or conditions such as skin , intestinal or joint problems and what medications your pet is on

Check off the following behaviors your dog shows when near windows, doors on on a walk

Pulling hard - dragging you

Barking continuously

Jumping up, barking and pulling

Growling at person entering, or what your dog is pulling towards on leash

Hiding behind you, pulling back, sitting down and not moving

Difficult to get focus - all ways weaving around, getting wound in my legs

I do not walk my dog

Describe the most recent incident of the primary problem behavior fully . Be sure to describe what your dog looked like - ears, tail, face if you can recall. If there were any bites indicate where on the body the bites were and if skin was broken. You may add a document if you need more room

Describe the most recent incident of the secondary behavior problem fully

List all trainers, tools, supplements and medications that have been used to improve the behavior problems

What is your expected or desired outcome from this behavior consultation?

I authorize Dr. Sally Foote to consult via telecommunication for the behavior, welfare and health evaluation of my pet. I approve all media recording of our sessions and submissions of media for the consultations. I assume responsibility for all fees incurred in this consultation and future professional services and any additional fees for products, late payment or other services. Fees are non-refundable for cancelation, or other reasons after a consultation has been provided.

The $60.00 appointment deposit may be credited to a future consultation with a minimum of 72 hour notice of appointment change.

Payment is due upon receipt of invoiced services. A minimum $5 fee will be assessed monthly to all balances over 30 days from invoice date. Any unpaid balance over 60 days will be sent to collections with all collection fees added to the balance for services. Typing in my full name is a form of electronic signature

Please allow up to 72 hours for a response from Dr. Foote's staff for all email contact.

A copy of your responses will be emailed to the address you provided.

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