Sheila H. Ferguson CBCC-KA CPDT-KA DipABT BEHAVIOR HISTORY FORM
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1 Sheila H. Ferguson CBCC-KA CPDT-KA DipABT BEHAVIOR HISTORY FORM Name Address Date Phone Name of Dog Breed Age Sex Neutered/Spayed? Age at Neutering What Brand of Food do you feed? Canned Food? How much How often Age of Dog when Acquired Where Number of Previous Homes Other Family Members and ages Other pets and ages Name any and all collars/harnesses/leashes you have used. Do you feel this has been effective in controlling your dog? What equipment have you used in the past? Relationship with Family Members and other pets Medical History
2 Date of Last Veterinary Visit Veterinarian s name Address Phone Current Medications and doses Dog s reaction to Vet visit Dog s reaction to strangers Dog s reaction to other dogs Dog s reaction to squirrels/rabbits etc. Dog s reaction to infants Dog s reaction to small children Dog s reaction to older children Dog s reaction to bicycles/skateboards/rollerblades Dog s reaction to cars Dog s reaction to large vehicles Known Previous History Age of Dog when Problem first arose Date of very first occurrence
3 Was any event associated with the onset of the behavior? Description of Problems/ Incidents Can you interrupt the behavior? How often does the behavior occur? What seems to trigger it? Describe what you have done to try to stop the behavior (Please list everything)and how the dog reacted Has the behavior gotten worse over time? Better? Stayed the same? Describe your goals for you dog You may be asked to change routine care and procedures such as exercise and interaction with your dog and to work Behavior Modification procedures into your daily activities. Are you willing and able to do this along with dedicating at least 15 minutes of rote training for basic commands daily? (circle one) Yes No
4 Where does the dog sleep? Have you consulted with a trainer/behaviorist or been to any classes? If yes, Who? When? Where? Describe a 24hr day routine Does your dog go to dog parks, daycare or stay with anyone? What is the schedule for this? What commands or tricks does your dog know and do willingly? How do you praise your dog? Is your dog afraid of anything? If yes, describe how your dog acts? Added Comments: THIS FORM IS FOR PAST HISTORY; DO NOT ATTEMPT TO TRY THEM AT THIS TIME.
5 Please star the appropriate box if your dog exhibits any of the listed behaviors at any time when you or any member of the family has done the following: DO NOT DO THESE THINGS Growl Lift Lip Touch dog's food or add food while eating Walk past dog while eating Take away real bone, rawhide, or delicious food Walk by dog when s/he has a real bone/rawhide Touch delicious food when dog is eating Take away a stolen object Physically wake dog up or disturb resting dog Restrain dog when it wants to go someplace Lift dog Pet dog Medicate dog Handle dog's face/mouth Handle dog's feet Trim the dog's toenails Groom dog Bathe or towel off Take off or put on collar Pull dog back by the collar or scruff Reach for or grab dog by the collar Hold dog by the muzzle Stare at the dog Reprimand dog in loud voice Visually threaten dog: newspaper or hand Hit the dog Walk by dog in crate Walk by/talk to dog on furniture Remove dog from furniture: physically or verbally Snap Bite No aggressive response Not tried
6 Make dog respond to command Does your dog get a glazed look in his/her eyes? Do you consider your dog hyperactive? Mark the appropriate answer History Yes No I don't know Did you acquire your dog after 3 months of age? Did you acquire your dog at 5 weeks of age or less? Was your dog acquired from a shelter or a pound? Has your dog had multiple owners during his/her life? Was your dog acquired from a pet shop? Was your puppy an orphan or hand raised? Was your dog the single puppy in a litter? Behavior No Mild Moderate Severe Does your dog follow you around the house? Does your dog become anxious at the sound of car keys? Does your dog become anxious when you put on your coat or shoes? Does your dog become aggressive when you leave? Does your dog exhibit other problem behaviors as you prepare to leave? Does your dog bark or whine excessively within 30 minutes of your departure? After you leave does your dog's activity decrease? After you leave does your dog appear depressed? After you leave does your dog have a loss of appetite? Only in your absence does your dog destroy property? Only in your absence does your dog urinate
7 or defecate in your home? Does your dog regularly have diarrhea, vomit, or lick excessively in your absence? Does your dog exhibit an excessive greeting on your return (jumping, hyperactivity, barking, more than 2-3 minutes)?
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Langford Vets BEHAVIOUR QUESTIONNAIRE FOR DOGS Alison Blaxter BA BVM&S Dip(AS)CABC PhD MRCVS Please fill in as much of this questionnaire as you can before your appointment. If you feel that the questions
Last name: First Name: Address: Street: City: Contact Number: ( ) - #children, Girls: ages: Boys: ages:
COLLEGE OF VETERINARY MEDICINE Purdue Animal Behavior Clinic Phone: 765-494-1107 Fax: 765-496-1025 Email: purdueabc@purdue.edu Patient Label F EL I NE BEHAVIOR HISTORY FORM Today s Date: (MM/DD/YYYY) /