IN-DEPTH CANINE HISTORY BEHAVIOR QUESTIONNAIRE

IN-DEPTH CANINE HISTORY BEHAVIOR QUESTIONNAIRE

Please fill out all areas of this form. The more complete the questionnaire, the better we can assess and help your pet.

  • GENERAL INFORMATION

  • MM slash DD slash YYYY
  • Max. file size: 100 MB.

  • PET INFORMATION (Click the + to add additional Pets/Rows)

  • Pet's NameBreedColorAgeWeightSex 
    Click + For Additional Rows For More Than One Pet
  • Pet's NameAge ObtainedWhere Did You Get This Pet?Breeder, if ApplicableBehavior of Litter-mates? 
    Click + For Additional Rows For More Than One Pet
  • Pet's NameNeutered/Spayed?Age Neutered?Any Change After Neutering? 
    Click + For Additional Rows For More Than One Pet

  • REASON(S) FOR CONSULTATION

  • Pet's NameProblemFrequency (Score Severity 1-10)Intensity (Score Severity 1-10)Duration of Behavior Each Episode (Score Severity 1-10)Onset – When Did Problem Start? 
    Click the + For Additional Rows For More Than One Problem And More Than One Pet

  • INFORMATION ON PRESENTING PROBLEMS

  • Put Pet’s Name Then Cause(s)
  • Pet's NameMedicationMg. StrengthFrequency (e.g. once a day, twice a day)How Long on Medication (e.g. days, weeks, months)Outcome (e.g. did the medication help yes/no?If Yes (what % improvement) 
    Click + For Additional Rows For More Than One Medication

  • FAMILY RELATIONSHIPS

  • First NameLast NameSexAge 
    Click + For Additional Rows To Add Addition Family Members
  • Pet's NameSpeciesBreedSex (Spayed/Neutered?)Age ObtainedAge Now 
    Click + For Additional Rows To Add More Pets

  • TRAINING

  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Household MemberSit %Down %Stay %Come %No % 
    Click + To Add Rows For Additional Household Members

  • PUNISHMENT

  • Please Check All That Apply

  • HANDLING

  • Please Check All That Apply

  • MEDICAL SCREEN

  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Please Check All That Apply
  • Pet's NameMedication Name:Dosage:Frequency Given (times per day)Duration Of Medication (how long taken) 
    Click + To Add Addition Rows Of Medications
  • Pet's NameSupplement Name:Dosage:Frequency Given (times per day)Duration Of Supplement (how long taken) 
    Please Click + To Add Additional Rows Of Supplements

  • REINFORCER ASSESSMENT

  • Pet's Name1.2.3.4.5. 
  • Pet's Name1.2.3.4.5. 

  • HOUSE-TRAINING SCREEN (If Your Pet Is Not House-soiling, Skip This Section)

  • DEPARTURE BEHAVIOR SCREEN

  • AGGRESSION SCREEN

  • Situations That Led To Aggression (Answer All That Apply)

  • AGGRESSION TOWARDS PEOPLE (If your Dog Is Not Aggressive Towards People, Skip This Section And Move To The Next)

  • AGGRESSION TOWARDS DOGS (If Your Dog Is Not Aggressive Towards Dogs, Skip This Section And Move To The Next)

  • ANXIETY/PHOBIA/FEAR/ SCREEN

  • Pet's NameTriggerFrequency (Daily, Weekly, Monthly etc.)Intensity Score (1-10) 10 Is Most SevereDuration (How Long Is The Anxiety Attack)Onset – When Did Problem Start? (How Long Ago) 
    Click + To Add Additional Rows For Additional Triggers

  • ADDITIONAL BEHAVIOR PROBLEMS

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