Sheila H. Ferguson CBCC-KA CPDT-KA DipABT BEHAVIOR HISTORY FORM

Similar documents
Canine Questionnaire

BULL TERRIER SURVEY. Date: Dog's Name: Recorder Registered Name: Address: Dam (mother): Telephone: Age of pet now. Fax: Age acquired pet

Age: Primary caretaker of dog: Other dogs in home (name, breed, sex, spayed/neutered), please list in order obtained:

BEHAVIOR ASSESSMENT INTAKE FORM

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

General Canine Behavior History

Tug Dogs Canine History Form

BEHAVIOR QUESTIONNAIRE FOR DOGS

BEHAVIOR QUESTIONNAIRE FOR DOGS

Veterinary Behavior Consultations, PC Ellen M. Lindell, VMD, DACVB Tel: ; Fax:

GENERAL INFORMATION PET INFORMATION REASON(S) FOR PRESENTATION INFORMATION ON PRESENTING COMPLAINT(S)

Incoming Dog Profile Revised 3/23/2016

Name: Address: Dog s Name: Spayed/Neutered. Yes No. How long have you had the dog? Where was the dog acquired?

INCOMING DOG HISTORY SHEET

Pooch Personality Profile

Rocky s Retreat Boarding/Daycare Intake Form

Canine Facilitated Adoption Profile. Owner s Name: Reason for Re-homing:

CAT QUESTIONNAIRE. This will help determine the possible cause(s), prognosis and management plan for their behaviour problem(s).

TRAINING & BEHAVIOR QUESTIONNAIRE

Canine Behaviour Consultation Form

Canine Behaviour Consultation Form

Off-Leash Play Application

New Client Questionnaire For multiple dog owners please complete one questionnaire for each dog.

White Oak Animal Hospital 10 Walsh Lane Fredericksburg, Va / fax

Dog Behavior Questionnaire

Pet Personality Profile

Pet Profile (please print one for each pet)

FELINE BEHAVIOUR CONSULTATION QUESTIONNAIRE

Canine Behavior Questionnaire

Canine Intake Profile. Owner s name: Owner s Phone#: Owner s Address Number: Street Name: Apt/Unit Postal Code: City:

AGGRESSION TOWARDS FAMILY MEMBERS HISTORY FORM

Fri. We will contact you to make an appointment for a private consultation. A. Owner Information. Owner s Name:

310 Carver Lane, East Peoria, IL Phone: (309) Fax: (309)

Daycare Application Form

Owner Information: Name: Veterinarian Information: Patient Information: Rabies Vaccination Status:

Incoming Dog Profile

CANINE BEHAVIOR CONSULTATION QUESTIONNAIRE

Please mail, fax, or this completed form at least 3 days prior to your appointment. Thank You. Today s Date: Owner s Name: Case #:

Dog Profile for Behavior Evaluation

Metro Dog Day Care and Boarding Program Application

Dog Behavior Problems Aggression Getting Started Safety and Management

OWNER SURRENDER CAT QUESTIONNAIRE

INCOMING CAT PROFILE

Cat Behavior Questionnaire

Dog Bite Prevention Handout written by Steph Callahan

Canine Behavioral Assessment & Research Questionnaire (short version)

Feline behavior consultation questionnaire

Ellen M. Lindell, V.M.D., D.A.C.V.B Telephone (845) / Fax.(845) P.O. Box 1605, Pleasant Valley, NY

General Information: Date and time of consultation (if scheduled): Clinic address: City/Town: Clinic phone: ( ) Who referred you to our service?

DOG ASSESSMENT FORM. In addition to completing the form from owner responses include your own observations wherever possible. Assessment.

Feline Questionnaire

GREAT COMPANIONS Pre-Consultation Behavior History Form

Camp Sunset Canine Behavior Assessment Questionnaire

Dog Profile. Dog s Information: About your Dog s History: Date: / / Animal ID (Staff Use Only): Dog s Name: Breed: Sex: (Check Box) Male Female

Connecticut Humane Society Canine Pet Personality Profile

DAYCARE INFORMATION FORM

DOG QUESTIONNAIRE. If you have specific questions you would like answered please bring these to your consultation.

Keep it Simple Stupid (K.I.S.S.) Dog Training American Kennel Club (AKC) Canine Good Citizen (CGC) Test & Info

BEHAVIOR QUESTIONNAIRE FOR CATS

Who referred you to us? Primary care veterinarian (doctor name, hospital name, and phone number):

BEHAVIOR QUESTIONNAIRE FOR CATS

Sex: Male Bitch. Is the dog: Spayed Neutered Entire. Type of Coat Short Semi Long haired

German Shepherd Rescue of New York, Inc. P.O.Box 242, Delmar, NY

Canine Behavior Pre-History Form Veterinary Behavior Specialists PO Box 1262 Clayton, CA 94517

Owner Surrender & Relinquishment Dog

CANINE SURRENDER PROFILE

DVGRR DELAWARE VALLEY GOLDEN RETRIEVER RESCUE, INC.

Happy Tail Dog Training LLC Colleen Griffith, Managing Member Canine Behavior Modification Consultation

Pawswise Client Questionnaire

From The Real Deal on Dogs by David Muriello. How to Choose a Great Dog (The Checklist)

FELINE BEHAVIOR CONSULTATION QUESTIONNAIRE

1 FELINE BEHAVIOR CONSULTATION QUESTIONNAIRE GENERAL INFORMATION PET INFORMATION ENVIRONMENT / LIFESTYLE

Cat Behavior History Questionnaire

CREATURE COMFORT EVALUATION TO QUALIFY FOR PET THERAPY CERTIFICATION

Enrollment Form, Pet Profile and Liability Release. Enrollment Form

Cat Profile. Animal ID (Staff Use Only) Cat s Name: Breed: Spayed or Neutered: (Check Box) Yes No Unknown Age: Date of Birth (If Known):

PLEASE TAKE CARE OF MY EPI DOG

PLAY ALL DAY, LLC REGISTRATION FORM

KPETS GROUP EVALUATION FORM FOR THERAPY TEAMS

DOG PROFILE FORM. First Name: Last Name: Address: Home Phone: Work Phone: Cell Phone: Name: Relationship: Phone Number:

FELINE BEHAVIOR CONSULTATION QUESTIONNAIRE

Northwest Battle Buddies

Potential Dog Survey

PAW PRINTS PET RESORT GUEST APPLICATION FORM

IDENTIFICATION AND MANAGEMENT OF SEPARATION ANXIETY IN DOGS

Emergency Contact Name Address Home phone Cell phone

Feline Intake Profile

Housetraining Your Adopted Dog

Surrendered Cat Information Date:

Please complete and return this questionnaire for private lessons. or posted to PO Box 248, Ourimbah, 2258.

Mile High Weimaraner Rescue Surrender Packet

Dog Surrender Profile

The Barking Orange Daycare Application (Updated September 2015)

Feline Behavior Questionnaire

PLEASE KEEP THIS PAGE FOR YOUR RECORDS

MARSAGAN LABRADORS. Training Exercise and Socialization Information Pack. Mrs N Marr 43 Diamantina Circle Karalee Qld 4306

ADOPTION APPLICATION. Please fill out this form completely. Completion of this application does not guarantee adoption.

Canine Behavior History Form Please complete and return form to GreenTree Animal Hospital 48 hours prior to your appointment.

BEHAVIOUR QUESTIONNAIRE FOR DOGS Alison Blaxter BA BVM&S Dip(AS)CABC PhD MRCVS

Last name: First Name: Address: Street: City: Contact Number: ( ) - #children, Girls: ages: Boys: ages:

Transcription:

Sheila H. Ferguson CBCC-KA CPDT-KA DipABT sjf@insight.rr.com BEHAVIOR HISTORY FORM Name Address Date Phone E-mail 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

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

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

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.

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

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

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)?

2024 © petsdocbox.com Privacy Policy | Terms of Service | Feedback