1. Veterinarian Name Contact Info. 2. Does your dog have any past or present medical conditions? Yes (Please describe) No
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1 Office Use Only Recorded by: edical History 1. Veterinarian Name Contact Info 2. Does your dog have any past or present medical conditions? Yes (Please describe) 3. Is your dog currently on any medication or special diet? Yes (Please describe) Behavior History 4. Including yourself, how many people of the following ages live in your house? 0-6mo yrs 7mo-3 yrs 15+yrs 4-9 yrs 5. What other animals did your dog live with, how many? other animals in household Dogs s Other (list) 6. How does your dog USUALLY respond to Never Encounter riendly Afraid Grumpy Ignores You and your family? Your other animals? eeting new adults? eeting new children? eeting new dogs? 7. Does your dog choose to interact, tolerate, or dislike children? Briefly describe. 8. Where does your dog spend most of his/her time? In the house not confined In the house in crate In the house restricted to one room Other (Please describe) Outside not confined Outside kennel Outside fenced yard Outside tied/tethered 3
2 9. Does your dog like his/her crate? Yes 10. Do you take your dog out to go to the bathroom? Yes (please specify how many times per day) Paper Trained 11. Does your dog usually have "accidents" in the house? Yes (please specify how many times per day) *12. When left alone, does your dog usually show any of the following behaviors? Urinate/Defecate in the house Bark/Whine/Howl Destroy household items Escape behavior Pace/Tremble/Drool ne of these ***I YOUR DOG USUALLY DISPLAYS ANY O THE ABOVE BEHAVIORS WHEN LET ALONE PLEASE COPLETE THE SEPARATION ANXIETY QUESTIONAIRE*** 13. Has your dog escaped your property 2 or more times in the last 6 months? Yes (Please describe) 14. Does your dog usually uncontrollably chase or attempt to chase any of the following? Walkers/Joggers with dogs Walkers/Joggers without dogs Bicycles/Skateboards/Roller bladers Cars/otorcycles Squirrels/cats/birds/other small mammals ne of these 15. What is your dog afraid of? 16. What are your dog s bad habits? 17. What are your dog s best qualities? 18. Please feel free to provide any additional information that we should know about your dog. 4
3 People-Directed Behavior 1. Please check all of the aggressive behaviors listed below that your dog has ever shown toward people. te: *Snap = bite at the air, dog s teeth do not touch skin **Bite = dog s teeth do touch skin (even if no visible damage) When did the aggressive behavior happen? Who was the aggressive behavior directed towards? What behavior did your dog show? Over Dog ood Over People ood/bones Over Toys or Objects When the dog was disturbed while sleeping or resting Over owner s attention During a Veterinarian Exam During handling? brushing, petting, being picked-up etc. When someone enters your house/yard? When seeing a person while on a walk with you? t Break Break Skin Show contact Skin ne Bark Growl teeth Snap* Bite** Bite** Total Number of Incidents
4 Bites to People (Please answer the questions below if your dog has ever bitten a person) 1. Check any warning behaviors your dog showed before biting a person. Bark Lunge Snap at air reeze Growl Bite without breaking skin Whale eye (whites of eye) Show teeth ne 2. Check the bite level of the most serious bite to a person. Level 1 - Teeth touch skin but no visible damage Level 2 - Teeth touch skin, minor surface abrasions possible, but no puncture. ay have red mark/minor bruise from dog s head or snout, may have minor scratches from paws/nails. Level 3 - Teeth scrape skin and cause bleeding. punctures. Level 4 - Punctures ½ the length of a canine tooth (or less), one to four holes, single bite. tearing or slashes. Victim not shaken side to side. Bruising. Level 5 - One to four holes from a single bite, one hole deeper than ½ the length of a canine tooth. Black bruising, tears and/or slashing wounds. Dog clamped down and shook or slashed victim. Level 6 - Any bite resulting in death of a person. 3. On what date did the most serious bite to a person occur? What caused your dog to bite? Where on the body was the bite located? 4. On what date did the most recent bite to a person occur? What caused your dog to bite? Where on the body was the bite located? 5. Please provide additional details about your dog s aggressive behavior to people below.
5 Animal-Directed Behavior 1. Please check all of the aggressive behaviors listed below that your dog has ever shown toward animals. te: *Snap = bite at the air, dog s teeth do not touch skin **Bite = dog s teeth do touch skin (even if no visible damage) When did the aggressive behavior happen? Who was the aggressive behavior directed towards? What behavior did your dog show? Over Dog ood? Over People ood/ Bones? Over owner s attention? When the dog was disturbed while sleeping or resting? When seeing an animal pass the house? When seeing an animal while on a walk with you? When meeting an animal while your dog was on leash? When meeting an animal while your dog was off leash? Show contact ne Bark Growl teeth Snap* t Break Skin Bite** Break Skin Bite** Total Number of Incidents
6 Bites to Animals (Please answer the questions below if your dog has ever bitten an animal) Check any warning behaviors your dog showed before biting an animal. Bark Lunge Snap at air reeze Growl Whale eye (whites of eye) Show teeth Bite without breaking skin ne Check the bite level of the most serious bite to an animal. Level 1 - Teeth touch skin but no visible damage Level 2 - Teeth touch skin, minor surface abrasions possible, but no puncture. ay have red mark/minor bruise from dog s head or snout, may have minor scratches from paws/nails. Level 3 - Teeth scrape skin and cause bleeding. punctures. Level 4 - Punctures ½ the length of a canine tooth (or less), one to four holes, single bite. tearing or slashes. Victim not shaken side to side. Bruising. Level 5 - One to four holes from a single bite, one hole deeper than ½ the length of a canine tooth. Black bruising, tears and/or slashing wounds. Dog clamped down and shook or slashed victim. Level 6 - Any bite resulting in death of an animal. 3. On what date did the most serious bite to an animal occur? What caused your dog to bite? Where on the body was the bite located? 4. On what date did the most recent bite to an animal occur? What caused your dog to bite? Where on the body was the bite located? 5. Please provide additional details about your dog s aggressive behavior to animals below.
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