CANINE BEHAVIOR HISTORY FORM. Household Information. Pet Info. List all other family members (names): Adults: Children: age age

Transcription

1 CANINE BEHAVIOR HISTORY FORM Klondike Canine academy Blair Animal Clinic/Klondike Kennels 3662 N 250 W West Lafayette, IN behavior@blairanimalclinic.com Date Name Patient (Pet s) Name: Address Zip Phone Alt. # Household Information List all other family members (names): Adults: Children: age age age age Who is the primary caretaker of this pet? Pet Info Order Name Breed Sex Neutered Age (yrs) adopted: Patient Y N Pet 2 Y N Pet 3 Y N Pet 4 Y N Pet 5 Y N Are any other pets currently ill? Y N Explain Vet s Name Phone Does this pet have any medical problems? Y N Describe: Medications

2 Patient Information Weight lbs BC score Thin Obese How long have you had this pet? yrs mo Age of pet when acquired: yrs mo Pet was acquired from: Pet Store Breeder Rescue (specify): Shelter Stray Other (specify): Age when this pet was spayed/ neutered: mos Reason for selecting this pet: yrs unknown Family pet Adult pet Childs pet Breeding Hunting Watch dog Outdoors only Service Showing Other Answer the following only if this dog was obtained as a puppy (< 6mos old): How was the dog raised in the previous home? Crate trained Outdoor Kennel/Garage Puppy Mill Barn/Farm Loose Outdoors Unknown How did you select this puppy from the litter? Breeder selected Most timid Biggest Smallest Most outgoing Looks/Color N/A other Daily Routine Average number of hours this pet is left alone on a daily basis: hours Where is this pet kept when alone? Crated Confined to a room Garage Basement Fenced yard Tethered outdoors Loose in house Outdoor kennel Where does this pet sleep at night? Crated Confined to a room Garage Outdoor kennel Basement Fenced yard Tethered outdoors Bedroom floor On person s bed Living Situation House Apartment Other Owned Rental Do you have a fenced yard? Y N Wood/Privacy Chain link Invisible Other

3 What forms of exercise does your dog participate in: Jogs with person Dog Park member Swimming Outdoors, unsupervised, runs free Outdoors, supervised, unleashed Access to fenced back yard, unsupervised Leash walks How long is each walk? minutes How often? Daily 1/week 2/week 3+/week seldom to never Exercise schedule is: Consistent Varies Dog is walked using: Flat collar Off-leash Retractable leash Harness Gentle Leader Headcollar Easy Walk Harness Choke chain Pinch/Prong Shock Collar Other: Does your dog pull on the leash? Yes No Sometimes I would like advice to help prevent my dog from pulling on leash Relationships/Interactions Children of various ages may be present and have access to your dog during a playgroup or training session. Is your dog comfortable around, able to be petted/touched and friendly with children of all ages? Yes No Unknown Is there anything we should know regarding your dog interacting with children? My dog has never played off leash before with dogs in a group setting My dog has played off leash with other dogs: (check all that apply) < 10 lbs < 25 lbs < 25 lbs only > 25 lbs only When interacting with other dogs I feel my dog: > 50 lbs is having fun does not want to play always gets picked on gets too rough/ I sometimes separate them is scared, runs, & hides tries to nip/snap at other dogs barks/lunges on leash has no opportunity to play with other dogs I do not know is not interested I m not sure how to interpret my dog s behavior when playing with other dogs How would you describe this pet s personality? (Check all that apply) friendly with strangers happy/outgoing aloof friendly with certain people shy/nervous fearful too attached to me anxious irritable fearful of noises

4 Training & Behavior History Has this dog ever attended training classes? puppy pre-school (< 4 months of age) obedience class Y N 4-H training Other: When? How old was the dog at the start of the class? mths Training Equipment Used: Where? yrs Flat collar Off-leash Retractable leash Harness Gentle Leader Choke chain Pinch/Prong Shock Collar Level of Training: Sit Perfect OK Needs work N/A Lie down Perfect OK Needs work N/A Come Perfect OK Needs work N/A Wait Perfect OK Needs work N/A Drop it Perfect OK Needs work N/A Leave it Perfect OK Needs work N/A Heel Perfect OK Needs work N/A Fetch Perfect OK Needs work N/A Other Perfect OK Needs work N/A Discipline Techniques: none ever startling scruff shake verbal reprimand time out physical reprimand ignore re-direct alpha roll over water pistol leash jerk grab collar distraction shock collar citronella collar Please check any of the following that are of concern with this pet: Jumps up on people Destructive chewing Inappropriate elimination Pulls on leash Growls Bites Aggressive to Humans Aggressive to Dogs Aggressive to Cats Too Attached to Me Fear biting Excessive energy Does not listen Does not come when called Protects food or toys from me Chases : Other :

5 Diet Brand: % % % % Dry Canned Treats Other Feeding Schedule: once/daily 2x/day 3x/day ad lib Treats (brand) Table food General Behavioral Profile KEY: Happy = experience is enjoyable, fully tolerates, asks for more Anxious = tolerates, but would prefer to avoid if possible, may shake, nervous, but does not attempt to growl, snap, or bite or run away. Aggressive = persistent barking, may lunge forward, intense focus on object: owner unable to distract, may need to be muzzled for procedure, attempts to growl, snap, or bite. Hyper = more than merely excited, may be combined with anxiety, persistent or repeats behaviors, difficult to distract. Fearful = nervous, anxious, attempts to escape, body posture reflects dog is prepared to run away or may attempts to growl, snap, or bite,(fight or Flight) Neutral = no response, dog does not care Unknown = do not know, has never been attempted or exposed

6 How does your pet react to the following: (See key on Previous Page) Happy Anxious Fearful Aggressive Excited Neutral Unk Unfamiliar person at door Being petted by person (on leash) Babies < 1 year 1-6 years 7-11 years years Bicyclists Rollerblades/Skateboarders Car rides Joggers Vehicles passing by (on leash) Doorbell/Knocking Vehicle/Loud Stereo/Pipes/Semi Going into crate/carrier Person passing on Sidewalk (on leash) Loud Noises Thunderstorms Owner reaching over/ petting on head Hugging Touching ears Nail trims Wiping feet Being lifted up Grasping by collar Putting on/taking off collar Being stared at Brushing Bathing Professional grooming Being approached when on dog bed Owner leaving Owner returning Being disturbed while asleep Being stepped over when lying on floor Verbal reprimand Physical reprimand Approaching bowl when eating Please check all behaviors that you are concerned with: Remove rawhide/pig ear from mouth Picking up food bowl while eating

7 Problem History Do you have access to a digital camera? Y N Video recorder? Y N You may also be asked to submit photos and video as this can be a vital source of information also. Please be as specific and as detailed as possible in your answers, using another sheet of paper or typing answers as needed. For each incident answer the following questions: What happens? Where does it occur? Who is present? What triggers the event? What does the dog look like (body language) just before the event and afterwards? How do you react to the event? What do you do specifically? Problem: Most recent incident: 2 nd most recent incident: 3 rd most recent incident: