Dog Behavior
Please Fill out this form in its entirety to the best of your knowledge
Email *
First and Last Name *
Pets Name *
How old was your dog when you got them? *
Has your dog had other owners? *
How long have you had your dog? *
Where did you get your pet? *
Why did you get this pet? *
When was the last time your pet saw a veterinarian? *
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DD
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What heartworm medication are you giving? *
What flea/tick medication are you giving? *
What food are you feeding *
How much per day? *
Does your dog have any medical issues that have been diagnosed? *
Do you take your dog on walks?  If yes, how many, and how long? *
Where do you keep your dog when you aren't home? *
Where do you live? *
Has your household changed since you got this pet?  If so, how? *
Do you know anything about this dog's litter mates and any behavioral or medical problems they have? *
Have you owned pets before? *
What kind? *
Where does this pet sleep? *
Have you done any training with your pet? *
Where or with who?  How old was your pet when you started?  Who took the dog?  How did they do? *
How well does your dog do with the following commands? *
Perfect
OK, needs work
Badly
Sit
Stay
Lie down
Wait
Heel
Fetch
Leave it/Drop it
Take it
What other people live in the house?  Please list name, age, sex,and  relationship.
Please list all animals in the household.  Include name, breed, age, age obtained, sex, whether they were in the household first and whether they have any medical or behavioral illness and what those problems are.
What made you contact us for a behavioral consult today?
Has the frequency or intensity of the problem changed since it first started? *
When did the problem start?
Are you concerned you may have caused the problem? *
Do you feel guilty about this problems *
Have you considered finding another home for this pet? *
Have you considered euthanasia (putting your pet to sleep)? *
Has your pet ever bitten a person or dog? *
Was there any legal action taken against you do to these bites?
Clear selection
When you leave the house does your dog do any of these behaviors? *
Yes
Don't know
No
Destructive Behavior
Urination
Defecation
Vocalization
Salivation
Panting
If the answer was yes to any of the above responses, do you know what the timing is? *
Does your dog react to any of these noises?
Salivate
Defecate
Urinate
Escape
Pant
Pace
Vocalize
Hide
Tremble
Destroy
Freeze
Will not eat food or treats
Column 13
Fireworks
Thunderstorms
Gunshot
Other Noises
This is the key for the following behaviors.  Please pick all that apply.  NR - No reaction, S - Snarl, L - Lift lip, B - Bark, G - Growl, SP - Snap, BT - bite, WD - Withdraw or avoid, NA - Not applicable *
NR
S
L
B
G
SP
BT
WD
NA
Take dog's food dish with food
Take dog's empty food dish
Take dog's water dish
Take human food that falls on the floor
Take rawhide
Take real bone
Take biscuit
Take toy
Human approaches dog while eating
Dog approaches dog while eating
Human approaches dog while playing with toys
Dog approaches dog while playing with toys
Human approaches/disturbs dog while sleeping
Dog approaches/disturbs dog while sleeping
Step over dog
Push dog off bed/couch
Reach towards dog
Reach over head
Put on leash
Push on shoulders
Push on rump
Towel feet when wet
Bathe dog
Groom dog's head
Groom dog's body
Stare at
Take muzzle in hands and shake
Push dog over onto back
Stranger knocks on door
Stranger enters room
Dog in car at toll botth
Dog in car at gas station
Dog on leash approached by dog on streeet
Dog on leash approached by person on street
Dog in yard - person passes
Dog in yard - dog passes
Dog in vet's office
Dog in boarding kennel
Dog in groomers
Dog yelled at
Dog corrected with leash
Dog physically punished
Someone rasise voice to owner in presence of dot
Someone hugs or touches owner in presence of dog
Squirrels, cats, small animals approach
Bicycles, skateboards
Crying infant
Playing with 2 year old children
Playing with 5-7 year old children
Playing with 8-11 year old children
Playing with 12-16 year old children
Untitled Title
Has anyone ever recommended training or any other treatment for the problems you are here for today?  Please tell us who recommended it, whether you tried it and what the outcome was?
Have you ever tried any of these things to help with the behavior and did it help?
Yes
No
Did it help?
Stare at or stare down
Grab by jowls and shake
Get an additional dog
Step on leash to force down
Blow in nose or face
Buy different toys
Metal choke collar
prong collar
Halti or head collar
Harness
No pull harness
Martingale collar
Shock collar
Citronella collar
Throw a can of pennies
Water pistol
Whistle
Hit dog
Step on dog's toes
Knee dog in chest
Alpha roll - hold on back
Growl at dog
Yell at dog
Time out
Praise for good behavior
Crate
Kennel outside
Fenced yard
Invisible fence
Hang by leash or collar
Leash correction
Muzzle
Increase exercise
Give treats for good behavior
Deprive of food
Thundershirt
Electronic avoidance systems/scat mat
Put dog's face into urine, feces, or thing they've chewed
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Pheromones
Anything else that you've tried?
Was there a change in the household or an event associated with the development of the behavior?  Please explain in detail if yes.
Is there a time of day when the behavior seems more or less intense?
Is there a person or another pet that seems to trigger the behavior or make it better?
Does the dog respond to its name or seem aware of its surroundings while in the midst of the behavior?
Clear selection
Can you convince the dog to stop the behavior?
Clear selection
Is there a location in which the dog prefers to perform the behavior?  Where?
Does any event r behavior routinely occur before the behavior begins?
Any changes in  elimination?
Any changes in appetite?
Any changes in ability to see or hear?
Any changes in mobility?
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