BEHAVIOURAL REFERRAL QUESTIONNAIRE
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- Bertina Adams
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1 New Milton Surgery and Office: Lymington Surgery: 14 Barton Court Road, New Milton 66 Milford Road, Pennington Hampshire. BH25 6NP Lymington, Hampshire SO41 BDU Telephone: Telephone: Facsimile: Facsimile: BEHAVIOURAL REFERRAL QUESTIONNAIRE BACKGROUND INFORMATION Name: Address: Contact numbers: Name of dog: Breed/ type: Age: Sex: If neutered when it was done: Early History: How old was your dog when you obtained it: Where did he/she come from? If from a rescue centre, why was he/she rehomed? Diet: What do you feed him/her? How many times a day is he/she fed and at what times? Does he/she enjoy their meals or are they picky? Do you give tit-bits? If so what? Exercise: What types of exercise does the dog have? How many hours of exercise per day? On or off lead? Does he/she exercise alone or with other dogs? Does he/she interact or play with other dogs? Does your dog have a favourite toy? Partners: R M B Wilson MA VetMB MRCVS Miss J Y Redman BvetMed MRCVS Mrs S C Tyler BvetMed MRCVS
2 What is your dog s favourite game with people? Where are the dog s toys kept? Does he/she have free access to them? Housing: Where does your dog sleep at night? Where does he/she stay when you go out? How often is he/she left and for how long? Are there any problems when you leave him/her? What happens? Is there access to the garden? When you are at home does the dog follow you around the house? Training history: Have you attended training classes with your dog? If so how old was the dog at the time? How long did you attend for? Did you have any problems with training? Does he/she come when called? Drop objects when asked? Walk to heel on walks? Family members: How many people are there in your household? If any children what are their ages? Does everybody interact with the dog? Do you have any other animals (type/age/sex)? Medical history: Does your dog have any current medical problems? Has she/he had any previous medical problems? Is he/she on current medication? 2
3 THE PROBLEM Describe the problem you are having with your dog in as much detail as possible (please use a separate sheet if necessary?) What happens immediately before your dog displays these behaviours? Please think back to both what you and the dog are doing before the problem occurs. What happens immediately after? When did the problem begin? Can you remember the first incident? How frequently does it occur? Is it becoming more frequent, less frequent or staying the same? Where does it occur? For example always in the same place? 3
4 Who is usually present at the time? Can you describe the last incident? When was it? If the dog is an entire bitch and is the behaviour related to her season? Do any related dogs have similar problems? Do any dogs in contact with him/her have similar problems? Have there been any previous attempts to cure this problem? (If so please describe) OTHER PROBLEMS Is your dog good: -with children? -with strangers? -with family members? - to groom or bath? - when you feed them? -with cats? -with loud noises? - when meeting other dogs? Would you describe your dogs as: -A fussy feeder? -Aggressive in any situation? -Aggressive to others dogs? -Nervous of anything? 4
5 -Bouncy and enthusiastic? -Sociable? -Confident? -Well trained? Are there any other problems with the dog? Is this your first dog? If not, what breeds of dogs have you owned previously? REHABILITATION How much time can you commit to working with your dog to solve these problems? What would you like to achieve? What would you envisage happening if the behaviour problem persists? Thanks very much for your co-operation in filling in this questionnaire. I will contact you soon and I look forwards to meeting you and your dog. Lucy Payne Jenkins, BSc hons, Dip CABC. A behavioural consultation typically involves a 1-2 hour appointment in your own home at a cost of which includes a full written report after your consultation. 5
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