Behaviour Questionnaire

Transcription

1 Behaviour Questionnaire Client Details Patient Details Owner to please complete this form and return to Murray Bridge Veterinary Clinic In order to help us with a diagnosis for your pet both background information and information specific to the problem need to be gathered. Please be as specific and detailed as you can in this form. You are welcome to use the back of the questionnaire or separate sheets of paper if you require more room. MEDICAL HISTORY Does your pet have any current health problems? If so are they on any medications currently for medical problems? (please list all medications and doses if possible) Has your pet had past health problems that required medication? (please list any medications and when they finished) Is your dog on any natural remedies or supplements or any other medications for its current behaviour problem? (Please list all and any responses) Is your dog on any routine health preventatives e.g worming, heartworm or flea preventatives (Please list all)

2 Is your dog desexed? If so at what age was this done? Has your dog ever been bred with? If so do you have any information about the behaviour of any offspring? BACKGROUND INFORMATION ON YOUR DOG How old was your dog when you acquired them? Where did you obtain your dog from? Why did you choose this breed? Have you owned pets before? Had your dog had other owners? If so, do you know why the dog was given up? Did you meet the parents of your dog? Can you describe their personality? Did you meet any siblings of your dog? How many were in the litter? Do you know of any behaviour problems in the siblings? How many animals did you have to choose from? Why did you choose this particular dog? HOUSEHOLD INFORMATION Please list the people that live in your household (please also indicate the ages of any children and the occupation of the adults). How many hours per day are the family members away from home? Please list any other animals in the household (include species/age/breed) What is your dog s relationship like with these other animals? e.g interacts well, dislikes, avoids What type of area/house do you live in? e.g suburbs, rural, single story/double story, houseboat Have you moved house/areas since acquiring your dog?

3 Has the household (people or pets) changed since acquiring your dog? DAILY SCHEDULE/ ROUTINE What is your dog s usual daily routine? What is your usual daily routine? Where does your dog sleep? Where does your dog eat? What is your dog fed and when? Is food left out? Do you give treats to your dog? Please list your dog s favourite treats in order of preference e.g. (1) liver treats (2) cheese (3)sausage (4) chicken pieces What amount of time does your dog spend indoors/outdoors? Do you exercise your pet? What type of exercise and for how long? e.g. leash walks, free running at dog park, games in the yard. Do you play games/play with toys with your dog? Please list any favourite toys/games Is your dog housetrained? Does your dog ever urinate/defaecate in the house? When you are out where is your dog left? (Indoors/outdoors) If your dog is left alone inside where are they left? When you have visitors where is the dog usually?

4 How does your dog react when you leave the house? How does your dog react when you arrive home? GENERAL BEHAVIOUR INFORMATION How does your dog react during thunderstorms? How does your dog react during fireworks? Does your dog react to any other types of noises? (Please specify type of noise and reaction) Does your dog bark? If so describe when/where/for what reason e.g. to greet, in excitement, at people, other dogs etc How does your dog react to: Strangers - Children - Familiar people - Unfamiliar visitors - At the vets - At the dog groomers/bathers - With other dogs - With other animals Has your dog had any training? E.g. puppy school, obedience school, other How did your dog act at training? How well does your dog respond to these cues: Sit Stay Drop or lie down Heel Retrieve/fetch How well does your dog walk on a lead? What equipment do you use to walk your dog? e.g. collar, choker chain, head halter, walking harness PRESENTING PROBLEM

5 What is the reason/reasons you are seeking help? What is the main behaviour that concerns you about your dog? Why is this behaviour a problem for you/ your dog? Are there other behaviours that concern your about your dog? How often does the main problem behaviour occur? (e.g. daily, weekly, monthly, occasionally) Has the frequency of the problem changed? (If so can you think of any factors that may have caused this?) Has the intensity of the problem changed over time? If so is it getting better/worse? Can you predict when the problem will occur? When did the problem first occur? (please describe this first incident) Please describe the three most recent incidents of the problem (please use as much detail as possible, where/when, what happened, who was present, what was the reaction of the people, what was the reaction of the dog?) MOST RECENT INCICENT:

6 2 ND MOST RECENT INCIDENT: 3 RD MOST RECENT INCIDENT: Have you tried anything to manage the problem? If so, what did you try and how effective was it? Do you consider this problem mild, moderate, or severe? What is your goal for the management/treatment of this problem? For example Being able to walk the dog without it barking at other dogs. I would like my animal to be calm during storms. I would like my cat to use the litter tray rather than spraying. I would like my pet to be less destructive at home Please add anything further that you feel has not been covered by the questions and is relevant to the problem. Thank you. Your contact details: Home Phone Mobile