Age: Primary caretaker of dog: Other dogs in home (name, breed, sex, spayed/neutered), please list in order obtained:
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1 Canine Behavior History Form Please complete the following information with as much detail as possible. Please return the completed form to Magrane Pet Medical Center via or bring it to the clinic, at least 48 hours before your appointment. Name: Phone number: Address: Patient Information: Name: Breed: Age: Date of birth: Sex: Male Female Spayed/neutered? Yes No Age: Household information: Number of adults, > 18 yrs old (name, age, sex): Number of children (name, age, sex): Primary caretaker of dog: Other dogs in home (name, breed, sex, spayed/neutered), please list in order obtained: Any other animals in home (species, age) please list in order obtained: Please describe how the pets get along: 1
2 Background information: 1. Age pet was obtained: 2. Where did you obtain your dog: Own breeding Breeder Shelter/Rescue Other (Please describe) 3. What is the primary purpose of your dog? Adult s pet Farm/outside dog Children s pet Hunting dog Family pet Obedience Breeding Service/working dog Show dog Watch/Guard dog 4. If obtained as a puppy, how did you select your dog from a litter? Biggest/dominant Most outgoing Breeder selected Most timid Appearance Smallest/submissive 5. Did you meet your dog s parents or have information about litter mates? If so, please describe: 6. If your dog was previously owned, what was his/her primary purpose? Adult s pet Obedience Children s pet Service/working dog Family pet Show dog Breeding Watch/guard dog Farm/outside dog Research/teaching Hunting dog Unknown 7. How would you describe your dog s personality as a puppy? Aggressive to owner Friendly to strangers Aggressive to strangers Happy/outgoing Aloof Hyperexcitable Anxious Inhibited Fearful Shy of strangers Friendly to owner Submissive N/A Unknown 2
3 8. How would you describe your dog s personality now? Aggressive to owner Friendly to strangers Aggressive to strangers Happy/outgoing Aloof Hyperexcitable Anxious Inhibited Fearful Shy of strangers Friendly to owner Submissive Unknown 9. Any additional comments about your dog s personality? Medical information 1. Please list all previously diagnosed medical problems and how they were treated 2. Please list any current medical problems 3. Please list all current medications and/or supplements your dog is currently receiving: General information 1. How much time does your dog spend indoors (%), outside (%): 2. Where does your dog stay when left alone? 3
4 3. Where does your dog sleep at night? 4. How many times is your dog walked per day? 5. Average hours of walking exercise daily? 6. What is your dog walked on? Off leash Flat collar Reason: 7. Diet Food (brand, type): Treats (brand, type): Choke collar Pinch collar Harness Head halter Does your dog finish each meal? Yes No Frequency of meals: /day Where is the dog fed? 8. Play Does your dog play with toys? What are his/her favorite toys? 9. Daily schedule Average # hours dog left alone per weekday: Consistent Varies Schedule on weekdays: 4
5 10. Have there been any major changes in your dog s environment/schedule since you obtained the dog? If so, please describe the changes, when they occurred, and how you think they affected your dog? Behavioral conditioning and training 1. Types/level of training, check all that apply to your dog Crate trained Attended obedience classes Attended puppy classes Shown in trials 2. Types of discipline, check all that apply Verbal reprimand Startle Training device Physical Time out Trained for other work Trained service dog 3. What method did you when house training your dog? At what age was your dog house trained? Does your dog ever eliminate in the house now? 4. Does your dog know any commands? Who trained your dog? Does your dog follow commands better from certain people or in certain places/situations? 5. What techniques were used to train your dog? 5
6 6. Did you, or anyone else, use any of the following draining tools to train your dog? (Please check all that apply) Flat collar Choke chain or choke collar Prong collar Citronella spray Other spray collars Ultrasonic or shock collar Leash Head Halter Harness Whistle Clicker Treats Toys 7. How does your dog respond to being crated? Chief Complaint: 1. What is the main behavior problem or chief complaint? 2. When did the problem first begin? 3. How often does the problem occur? 4. What is the severity of the problem: per day per week per month Very serious Serious Not serious 5. Have you identified any triggers for the problem (when, where, presence of people/other animals, circumstances)? 6
7 6. Describe the first incident of the problem in detail. When and where did it occur? People and animals present? What did your dog do and what did he/she look like? How did you react? Was there a trigger for the incident? 7. Describe the most recent incident in detail: 8. Describe any other incident(s) you believe may be relevant, including the most severe incident (if not reported above): 7
8 9. Has there been a change in intensity, appearance, and/or frequency of the problem since it started? If so, please describe how it has changed. 10. What has been done previously to correct the problem? Did it change the behavior? 11. Have you considered euthanasia or rehoming your dog because of this problem? Yes No 12. Do you have any further comments about this problem? 13. What are your goals for this behavior consultation relating to this problem? If there are other behavior problems you would like addressed, please complete questions 2-12 above for each additional problem. 8
9 Aggression profile Please review the list of situations below and check all reactions your dog has displayed, even if it only occurred once. A familiar person may be a family member or people with whom the dog has interacted regularly. Situation Unfamiliar person at door Unfamiliar person in home Unfamiliar person outside car Unfamiliar person on leash off property Unfamiliar person off leash off property Bicycles, roller blades, joggers on walk Babies (non-family member) Children (non-family member) Veterinary staff at vet clinic Staff at groomer/boarding kennel Unfamiliar dog on leash off property Unfamiliar dog off leash off property Unfamiliar dog from property Unfamiliar dog outside car Owner trimming nails Owner medicating Owner grooming Owner bathing Owner wiping feet Owner petting dog elsewhere Owner lifting dog up Owner putting on/taking off collar Owner reaching over/petting on head Owner reaching/grasping collar Owner playing rough Owner walking by food while dog eats N/A Growls / No aggression Barks shows teeth Lunges or snaps (no contact) Bites (contact) Comments 9
10 Owner grabbing food dish while dog eats Owner taking away bone/toy/stolen object Owner approaching dog on bed/crate Owner disturbing sleeping dog Owner stepping over lying dog Owner giving verbal reprimand Owner giving physical punishment Owner staring at dog If your dog has ever bitten anyone, please describe the incident(s) below Individual bitten (Name, relationship to dog) Situation Part of body bitten Severity (was skin broken, etc.) 10
11 Fear and Anxiety Profile Please review the list of situations below, if your dog displays any of the following behavior, please check the box that best describes the frequency of the behavior. 1. Never (0%) 2. Sometimes (<50%) 3. Often (50-80%) 4. Almost always (>80%) 5. Unknown/Not applicable Follows you around the house Becomes anxious when you leave Becomes aggressive when you leave Barks/whines excessively within 30 minutes of departure Decrease activity level after you leave Lose appetite after you leave Becomes destructive only in your absence Eliminates in home only in your absence Excessive greeting when you return home Fearful of people Fearful of other dogs Fearful of other animals Fearful of noises Fearful of thunderstorms Fearful of new objects Fearful of inanimate objects (vacuum, broom, etc.) Please check any of the following behaviors displayed during the listed situations: 1. Owners leaving Destruction (furniture, carpet, door) Salivation Elimination (urination/defecation) Vocalization Hiding Shaking Pacing Panting Staying near you Excessive drinking 2. Thunder Destruction (furniture, carpet, door) Salivation Elimination (urination/defecation) 3. Loud noises (other than thunder) Destruction (furniture, carpet, door) Salivation Elimination (urination/defecation) Vocalization Hiding Shaking Pacing Vocalization Hiding Shaking Pacing Panting Staying near you Excessive drinking Panting Staying near you Excessive drinking Thank you for taking to time to fill out this questionnaire, we look forward to working with you. 11
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