VETERINARY BEHAVIOR CONSULTATIONS OF COLORADO E Lise M Christensen Bell, DVM DACVB Ariel Fagen, DVM 21448 E Crestridge Pl Centennial CO 80015 Phone (720) 306-9601 Fax (720) 306-9602 www.behaviorvets.com Email BehaviorVets@gmail.com CANINE BEHAVIOR HISTORY Thanks to many behaviorists and, especially, the Animal Behavior Clinic at Cornell University for contributing to this history form. * = required information CLIENT INFORMATION Primary Owner Name Address 1 Address 2 City ST ZIP Email Address Phone(s) Req Data Entry * 1 st : ( ) - Cell 2 nd : ( ) - Cell Other Owner s Name Address 1 Address 2 City ST ZIP Email Address Phone(s) 1 st : ( ) - Cell 2 nd : ( ) - Cell Consultation Location (required for housecall) Pet Name Species Breed Age and DOB Color Male/Female Neutered/Spayed Last Weight and Date * Same as above. * Dog Yrs / / When adopted? Male Female Intact Neutered/Spayed If so, at what age or when? lbs kg Date last weighed: / / Veterinarian Clinic Name Address 1 Address 2 City ST ZIP Email Address Phone Office: ( ) - Fax: ( ) - Referred by v 3-2-2015 Page 1 of 25
BEHAVIOR CONCERN * Rank your dog s behavior(s) of concern to you, how much of a problem you consider the behavior, and when you first noted. 1 * Very serious Serious Annoying First Noted: 2 3 4 5 Describe concerns in order of occurrence. FIRST behavior incident you remember: Date and time? Who was present? What occurred? Dog s body language tail up/down, ears up/back, etc.? Your response? Any injuries to whom, to what extent? MOST RECENT incident in same detail: Date and time? Who was present? What occurred? Dog s body language tail up/down, ears up/back, etc.? Your response? Any injuries to whom, to what extent? SECOND MOST RECENT incident in same detail: Date and time? Who was present? What occurred? Dog s body language tail up/down, ears up/back, etc.? Your response? Any injuries to whom, to what extent? THIRD MOST RECENT incident in same detail: Date and time? Who was present? What occurred? Dog s body language tail up/down, ears up/back, etc.? Your response? Any injuries to whom, to what extent? OTHER significant incidents: Date and time? Who was present? What occurred? Dog s body language tail up/down, ears up/back, etc.? Your response? Any injuries to whom, to what extent? * Very serious Serious Annoying First Noted: Very serious Serious Annoying First Noted: Very serious Serious Annoying First Noted: Very serious Serious Annoying First Noted: v 3-2-2015 Page 2 of 25
Describe the ranked concerns by intensity, frequency and your response to the concern. Concern #1 * How often do you note the behavior? How many times in that period do you Daily Weekly Monthly note the behavior? 1-2 3-5 6-10 Has the problem changed in intensity? Increased No Decreased In frequency? How have you tried to correct this? Did any techniques help? Make the problem worse? Increased No Decreased Concern #2 How often do you note the behavior? How many times in that period do you note the behavior? Has the problem changed in intensity? In frequency? How have you tried to correct this? Did any techniques help? Make the problem worse? Concern #3 How often do you note the behavior? How many times in that period do you note the behavior? Has the problem changed in intensity? In frequency? How have you tried to correct this? Did any techniques help? Make the problem worse? Concern #4 How often do you note the behavior? How many times in that period do you note the behavior? Has the problem changed in intensity? In frequency? How have you tried to correct this? Did any techniques help? Make the problem worse? Concern #5 How often do you note the behavior? How many times in that period do you note the behavior? Has the problem changed in intensity? In frequency? How have you tried to correct this? Did any techniques help? Make the problem worse? Note the various disciplinary techniques you use for these behaviors and other problems. * Daily Weekly Monthly 1-2 3-5 6-10 Increased No Decreased Increased No Decreased Daily Weekly Monthly 1-2 3-5 6-10 Increased No Decreased Increased No Decreased Daily Weekly Monthly 1-2 3-5 6-10 Increased No Decreased Increased No Decreased Daily Weekly Monthly 1-2 3-5 6-10 Increased No Decreased Increased No Decreased v 3-2-2015 Page 3 of 25
HOUSEHOLD * Name any people living in your household. Age Occupation Relationship to each other Hrs away from home Name the other animals in the house in the sequence obtained. * Species Breed Age at adoption Age now Describe your dog s relationship with the other animals, i.e., friendly, hostile, fearful, etc. Describe the locale where your dog spends most of his/her time. Describe the type of dwelling where your dog spends most of his/her time. *Include a floor plan of each level of the main residence. Describe the location and floor plan of any secondary residence/vacation home. City/town Suburbs Rural Studio/ 1 BR 2 BR Apt/ condo Townhouse duplex House/ trailer Ranch/ Farm If your dog travels frequently, describe the method of travel and how tolerated. How many times have you moved since acquiring your dog? Describe changes in environment. Describe how your household, including people/animals, has changed since acquiring your dog. v 3-2-2015 Page 4 of 25
DOG S BACKGROUND * Why did you decide to get a dog? Have you owned dogs before? Why did you choose this breed, sex, color? Where did you get this dog? Shelter/ rescue Stray Friend Newspaper Pet store Breeder Referral Serious Breeder Backyard Breeder Other describe. If known, how many littermates? Male/female? How many did you choose from? Specifically, why this dog over others? Describe any temperament test or behavioral evaluation performed. Describe your dog s behavior as a puppy. Favorite time and activity to share? Best behavior performed? Has the dog had other owners? How many? Why was the dog given up? If your dog is intact, has he/she ever been bred? Are you planning to breed? If you have an intact female, when was her last heat? Was it normal? At what age was your dog neutered/spayed? Were there behavior changes after neutering? Yrs Yes No If so, describe. v 3-2-2015 Page 5 of 25
MEDICAL HISTORY * Previous Illness/Injury Date of onset Date resolved Medications and doses used Has your dog ever been diagnosed with a seizure disorder? Does your dog have any problems with skin or ears, i.e., scratching, redness, greasy, hair loss, etc.? Has your dog ever been diagnosed with any bone or muscle problems? Does your dog have chronic sneezing or coughing? Does your dog have periodic diarrhea or gastrointestinal distress? Medications used in the past for MEDICAL problems: Yes No If so, describe: Yes No If so, describe: Yes No If so, describe: Yes No If so, describe: Yes No If so, describe: Dose and frequency Date begun/ ended Side-effects Medications used in the past for BEHAVIORAL problems: Dose and frequency Date begun/ ended Side-effects List any supplements you have tried or are currently administering for any problems. Dose and frequency Date begun/ ended Side-effects v 3-2-2015 Page 6 of 25
DIET AND FEEDING * What do you feed your dog? Brand Amount Where Time of day % Protein (from dog food label) How has your dog s appetite changed? Increased Decreased No change. If so, describe. Who feeds the dog? Where? Where does your dog drink? List your dog s five favorite treats from the most to least including any human food treats your dog likes. How often do you give treats? For what? Most Least DAILY SCHEDULE * Describe a typical 24-hr day in your dog s life. How does your dog behave with familiar visitors? With unfamiliar visitors? Does your dog behave differently with children? Differently with familiar vs unfamiliar children? Differently with toddlers and babies? How do you exercise your dog? How do you play with your dog? What toys does the dog have? What toys does your dog prefer? How many exercise/walk sessions does your dog get daily? For how long? How many play sessions does your dog get daily? How many training sessions does your dog get daily? How often do you groom your dog? Take the dog to the groomer? Is your dog housetrained? Does your dog ever eliminate in the house? Does your dog jump on you or others without permission? Paw at you or others? Lick you? Mount? Does your dog ever bark at you? Bark at other times? What is your dog s activity level in general? Runs free Runs free but supv. Fenced yard Kenneled run Leash walked Tied outside Yes No If so, how? Urinate Defecate Both No Walks Indoors only Yes No Yes No Yes No Yes No If so, whom and/or what? Yes No If so, describe. Yes No If so, describe. Low Average High Excessive If so, describe. Dog park Outdoors only v 3-2-2015 Page 7 of 25
SOCIAL BEHAVIOR * Specifically where does your dog sleep at night? Where is his/her favorite sleep spot? Has your dog s sleep changed in pattern or length? Have you ever used a crate or room to confine your dog? Do you still use the crate or room? Where is your dog when alone in the house? When you have guests? What percentage of the day does your pet spend inside? Outside? How does your dog behave while you are leaving the house? When you return? Yes No If so, describe. Yes No If so, describe your dog s reaction. Yes No If so, what for? If not, why? v 3-2-2015 Page 8 of 25
TRAINING * What training has your dog had? How old was your dog when training started? What type of training collar was used? None Home- Taught Agility Flyball Private Yrs Describe Started class Graduated Class Graduated 2+ classes Other describe. Trainer s Name Response Grade 1-5 Good-poor None (off leash) Neck collar Remote collar (shock, citronella) Head halter Body harness Who in the family is the primary trainer? Have you or do you plan to exhibit your dog in Yes No If so, describe. breed shows or dog sports? Describe any awards or titles your dog has. Has your dog had any of these specialized training classes? Hunting Herding Protection Attack Schutzhund What percent of the time does your dog obey the following commands for each member of the family? Family Member Name Sit Down Stay Come Heel (don t pull) Will your dog settle or relax on command? Yes No If so, describe. Describe the training you tried with your dog. Rewardbased Assertive/ dominance/ pack style Aversive/ mostly corrections Other - describe: Describe your dog s reaction to any of the following if you have used for punishment OR training. Physical contact Behavior stopped/diminished Behavior worsened/intensified Describe. Noise (shaker can, siren) Behavior stopped/diminished Behavior worsened/intensified Describe. Ultrasonic Behavior stopped/diminished Behavior worsened/intensified Describe. Water sprayer Behavior stopped/diminished Behavior worsened/intensified Describe. Verbal reprimands Behavior stopped/diminished Behavior worsened/intensified Describe. Muzzle grasp Behavior stopped/diminished Behavior worsened/intensified Describe. Pinning/alpha roll Behavior stopped/diminished Behavior worsened/intensified Describe. Time-out Behavior stopped/diminished Behavior worsened/intensified Describe. Booby-traps/repellants Behavior stopped/diminished Behavior worsened/intensified Describe. Punishment Is any punishment effective? Yes No If so, what? What punishment is most effective? v 3-2-2015 Page 9 of 25
Are others needed? Does the behavior decrease in frequency or intensity over the course you use this punishment? Describe any punishment that makes the problem worse. Describe any punishment that led to threatening behavior, aggression or fear. Does your dog respond differently to punishment from different family members? Yes No If so, what? Yes No If so, describe. Yes No If so, describe. v 3-2-2015 Page 10 of 25
AGGRESSION SCREENING * Fill out even if aggression is not the main problem. Not all of these situations are appropriate ways to interact with a dog. Do NOT try these situations if you don t already know what might trigger your dog. Screen can be used in several ways: 1) to note presence/absence of a behavior; 2) as a log noting number of occurrences, times attempted during a period of time; and/or 3) as a log noting frequencies to compare to #2. Key: None = no reaction Snarl = lifted lip, noise Bark = aggressive bark Growl = serious, not play Snap = no skin contact Bite = skin contact Withdraw = cower, avoid N/A = not applicable; never been in that situation +/- = increasing/decreasing What is your dog s response to: Family petting the dog Family hugging the dog Family kissing the dog Family lifting the dog Family calling off furniture Family pushing/pulling off furniture Family approaches on furniture Family disturbs while resting/sleeping Family approaches while eating Family touches while eating Family takes dog food away Family takes water dish away Family takes rawhide Family takes biscuit/cookie Family takes real bone Family approaches when dog has any object/toy/bone Family verbally punishes Family poses visual threat, i.e., stare, wave arms at dog Family speaks to dog in normal tone Family stares at dog Family bends over dog Family pushes on shoulders or back v 3-2-2015 Page 11 of 25
What is your dog s response to: (cont) Family approaches dog near spouse Family enters room Family leaves room Family reaches toward dog Family uses leash restraint Family uses collar restraint Family uses scruff restraint Family takes leash off/on Family puts collar on/off Family bathes dog Family towels dog Family grooms/brushes dog Family trims nails Family uses leash/collar correction Family uses sit Family uses down Familiar adult enters house/yard Familiar child enters house/yard Response to familiar toddler/child Familiar adult approaches owner and dog on leash Familiar child approaches owner and dog on leash Stanger petting the dog Stranger hugging the dog Stranger kissing the dog Stranger lifting the dog Stranger calling off furniture Stranger pushing/pulling off furniture Stranger approaches on furniture v 3-2-2015 Page 12 of 25
What is your dog s response to: (cont) Stranger disturbs while resting/sleeping Stranger approaches while eating Stranger touches while eating Strange takes dog food away Stranger takes water dish away Stranger takes rawhide Stranger takes biscuit/cookie Stranger takes real bone Stranger approaches when dog has any object/toy/bone Stranger verbally punishes Stranger poses visual threat, i.e., stare, wave arms at dog Stranger speaks to dog in normal tone Stranger stares at dog Stranger bends over dog Stranger pushes on shoulders or back Stranger approaches dog near spouse Stranger enters room Stranger leaves room Stranger reaches toward dog Stranger uses leash restraint Stranger uses collar restraint Stranger uses scruff restraint Stranger takes leash off/on Stranger puts collar on/off Stranger bathes dog Stranger towels dog Stranger grooms/brushes dog Dog at groomer s v 3-2-2015 Page 13 of 25
What is your dog s reponse to: (cont) Stranger trims nails Stranger uses leash/collar correction Stranger uses sit Stranger uses down Adult stranger enters house/yard Child stranger enters house/yard Response to toddler/child stranger Stranger adult approaches owner and dog on leash Stranger child approaches owner and dog on leash Response to strangers when off leash Dog at veterinary clinic Dog in car, sees people/animals at tollbooths, gas stations Dog in house, sees people/animals outside Response on leash to other dogs Response off leash to other dogs. Characteristics of Aggressive Episodes Attacks are sudden and surprising. Yes No Episodes appear unprovoked. Yes No Dog is abruptly docile afterward. Yes No Dog appears sorry afterward. Yes No Episodes associated with glazed or absent Yes No expression. I can usually tell what will set off my dog. Yes No The behavior is new and uncharacteristic. Describe a typical aggressive episode, e.g., growl, lunge, bite, etc. What is the usual circumstance? Yes No Given the same situation 10 times, how many result in aggression? Has the frequency or intensity of the behavior changed since the problem started? Does your dog exhibit periodic diarrhea or gastrointestinal distress? 0 1 2-3 4-5 6-7 8-9 >10 Yes No If so, describe. Yes No If so, describe. v 3-2-2015 Page 14 of 25
Episodes of Human-Directed Aggression If your dog bit as a puppy, at what age? Describe the first time your dog growled at a person. At what age? Describe the first time your dog snapped or bit at a person. At what age? If your dog has bitten a human, total number of bites? 0 1 2 3 4 5 >5 Does your dog bite more than once per episode? Yes No If so, describe: 1 Pre-Bite (air bite) Human Bite Levels Number of bites by severity? Number of bites to part of the body? Face Torso Arms Legs M/F 2 Near Bite (tooth contact, no puncture) 3 Shallow Bite (less than depth of canine tooth) Who is/are the targets of aggression? Infant/Child/Adult Dark/Light Skin Tall/Short Carrying Box/Cane/Umbrella Hat/Uniform How many bites to humans were reported? To whom were they reported, i.e., local authorities, hospital, human society? Was legal action taken? Yes No If so, describe: 4 Deep Bite (depth of canine tooth) 5 Multiple Bites (deep and multiple) Episodes of Dog-Directed Aggression If your dog has bitten another dog, total number of bites? 0 1 2 3 4 5 >5 Bite Levels 1 Pre-Bite (air bite) 2 Near Bite (tooth contact, no puncture) 3 Shallow Bite (less than depth of canine tooth) Number of bites by severity? How many bites to dogs were reported? To whom were they reported, i.e., local authorities, hospital, human society? Was legal action taken? Yes No If so, describe: 4 Deep Bite (depth of canine tooth) 5 Multiple Bites (deep and multiple) 6 Lifethreatening (flesh consumed or victim death) 6 Lifethreatening (flesh consumed or victim death) v 3-2-2015 Page 15 of 25
ANXIETY AND FEAR REACTIVITY SCREEN * Behavior While ACTUALLY Alone or Totally Without the Client Destructive behavior Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Inappropriate urination Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Inappropriate defecation Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Vocalization barking, whining, etc. Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Salivation drooling, slobbering, etc. Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Panting Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Behavior While VIRTUALLY Alone, i.e., client is home but not accessible, door closed, etc. Destructive behavior Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Inappropriate urination Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Inappropriate defecation Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Vocalization barking, whining, etc. Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Salivation drooling, slobbering, etc. Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Panting Always Frequently Occasionally Seldom Never Don t Know If so, within 5 min 5-30 min 30-60 min 1-3 hrs only after 3 hrs Reactions to Noise Thunderstorms Does your dog react to other aspects of storms? Fireworks Gunshots/backfires Salivate Defecate Urinate Always (>95%) No reaction Escape Pant Pace Frequently Don t know Hide Tremble Destroy Occasionally Freeze Won t eat Pupils dilate Rarely Vocalize (bark, whine, growl, howl) Never Wind Yes No Don t know Darkness Yes No Don t know Ozone Yes No Don t know Barometric pressure Yes No Don t know Rain Yes No Don t know Hail Yes No Don t know Salivate Defecate Urinate Always (>95%) No reaction Escape Pant Pace Frequently Don t know Hide Tremble Destroy Occasionally Freeze Won t eat Pupils dilate Rarely Vocalize (bark, whine, growl, howl) Never Salivate Defecate Urinate Always (>95%) No reaction Escape Pant Pace Frequently Don t know Hide Tremble Destroy Occasionally Freeze Won t eat Pupils dilate Rarely Vocalize (bark, whine, growl, howl) Never v 3-2-2015 Page 16 of 25
Reactions to Noise (cont) Mechanics, i.e., vacuums, blowers, etc. Siren/alarms Cars/trucks How frequently do noise events occur in the dog s environment? Has this dog ever been treated for noise sensitivities or phobias? Salivate Defecate Urinate Always (>95%) No reaction Escape Pant Pace Frequently Don t know Hide Tremble Destroy Occasionally Freeze Won t eat Pupils dilate Rarely Vocalize (bark, whine, growl, howl) Never Salivate Defecate Urinate Always (>95%) No reaction Escape Pant Pace Frequently Don t know Hide Tremble Destroy Occasionally Freeze Won t eat Pupils dilate Rarely Vocalize (bark, whine, growl, howl) Never Salivate Defecate Urinate Always (>95%) No reaction Escape Pant Pace Frequently Don t know Hide Tremble Destroy Occasionally Freeze Won t eat Pupils dilate Rarely Vocalize (bark, whine, growl, howl) Never Frequently multiple times per week Regularly almost weekly Occasionally 2-3 times per month Almost never 2-3 times per year Yes No If so, describe: v 3-2-2015 Page 17 of 25
* Screen is used to evaluate the role previous treatment recommendations PREVIOUS TREATMENT SCREENING may play in your dog s problems or in their resolution first in a general sense and secondly for specific actions. General Approaches Suggested By whom Attempted Outcome Obedience class Private trainer Agility trainer Send to a shelter Place in another home Euthanize or kill Consult your vet Consult a non-veterinary behavior consultant Consult a veterinary behaviorist (DACVB) Make into working dog - guard, hunting, etc. Specific Approaches Suggested By whom Attempted Outcome Stare at or stare down Grab by jowls and shake Get a companion dog for this one Step on leash or choke collar and force down Blow in nose or face Provide different types of dog toys Fabric choke collar Metal choke collar Prong collar Halti, head collar or Gentle Leader Harness Pull or Sporn harness Martingale collar Scruffy Guider Electronic or shock collar by owner v 3-2-2015 Page 18 of 25
Specific Approaches (cont) Suggested By whom Attempted Outcome Electronic or shock collar by trainer Remote controlled or bark-activated electronic or shock collar Citronella collar Citronella spray Throw a tin or can of pennies Water pistol Whistle Foghorn Hit dog with hand Blow torch Hit dog with empty plastic soda bottle Hit dog with whiffle ball bat Hit dog with leash Hit dog with chain Hit dog with board, plank or baseball bat Hit dog under chin Step on dog s toes Knee dog in chest/belly Kick dog Bite dog Alpha roll (hold spread-eagle on back) Dominance down (hold down on side, legs extended, head flat) Growl at dog Yell or scream at dog Long down Sit and wait Time out (where, how and for how long) Praise for good behavior v 3-2-2015 Page 19 of 25
Specific Approaches (cont) Suggested By whom Attempted Outcome Crate Kennel outdoors Fenced yard Invisible fence Isolate in house (where and for how long) Board at vet Board at kennel Whip Chain Cattle prod String up, hang by leash and collar (all 4 feet off ground) Pop and jerk leash Yank or pull on leash Tie up physically Tie out or stake on very short lead hooked to wall or floor Muzzle Increase exercise Increase play Give treats for good behavior Deprive of food Throw against wall Beat with your fists Shove dog s nose/face into urine, feces or destruction Use scat mats or other electronic avoidance systems Calming cap Thundershirt or Anxiety Wrap Other: Other: v 3-2-2015 Page 20 of 25
REPETITIVE BEHAVIORS HISTORY Grooming Hallucinatory Consumptive Locomotory Vocalization Patterns of Repetitive Behavior Was there a change in the household or an event associated with the development of the behavior? Is there any time of day when the behavior seems more or less intense? Is there a person or another pet in the presence of whom the behavior seems more intense? Does the dog respond to its name or seem aware of the surroundings while in the midst of the behavior? Is the dog aware that you are calling him/her? Can you convince the dog to stop the behavior by calling him or her? By using physical restraint? List the kinds of things, i.e., noises, treats, toys, if any, that will interrupt the behavior once it has started. Is there a location in which the dog prefers to perform the behavior? For ingestion, list what types of objects are consumed as specifically as possible. Does any event or behavior routinely occur immediately BEFORE the behavior begins? Does any event or behavior routinely occur immediately AFTER the behavior begins? Has the dog s general changed in any way since the onset of the atypical behavior, i.e., the dog is more or less aloof, aggressive, withdrawn, playful, etc.? Has the dog s diet recently been changed> How old do you think your pet was when its ritualistic behavior began? * Complete or check only if your dog is showing repetitive or ritualistic behaviors that you find troublesome or about which you are concerned. Chewing self Biting self Licking self Plucking hair Barbering/trimming hair on self Continuously doing any of these behaviors to another individual If so, describe: Other If so, describe: Staring and fixating on things that are not there Tracking things that are not there Pouncing on or attacking things that are not there Other If so, describe: Consuming rocks Consuming dirt or soil Consuming other objects Licking or gulping air Eating, licking, sucking or chewing wool or fabric, rugs, furniture, etc. Other If so, describe: Circling/spinning Tail-chasing Freezing Other If so, describe: Rhythmic barking Howling Growling Other If so, describe: Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail what is going on at that time of day: Yes No Uncertain If yes, describe who this is and their association to the pet? Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Yrs v 3-2-2015 Page 21 of 25
Patterns of Repetitive Behavior (cont) Did any other dog in the dog s family exhibit these or similar behaviors? Is there a pattern to the behavior? Yes No Uncertain If yes, describe in detail: Yes No Uncertain If yes, describe in detail: Duration: Hrs Days Wks Mos Pattern after meals, in AM, etc.: v 3-2-2015 Page 22 of 25
AGE-ASSOCIATED BEHAVIOR SCREEN Locomotory/Ambulatory Appetite Elimination Complete ONLY if you have a dog more than 7 years old. Check only one No alterations or debilities noted. Modest slowness associated with change from youth to adult. Moderate slowness associated with geriatric aging. Moderate slowness associated with geriatric aging plus alteration or debility in gait. Moderate slowness associated with geriatric aging plus some loss of function, e.g., cannot climb stairs. Severe slowness associated with extreme loss of function, particularly on slick surfaces and may need to be carried. Severe slowness, extreme loss of function and decreased willingness or interest in locomoting spends most of the time in bed. Paralyzed or refuses to move. May check more than one No alterations in appetite. Change in ability to physically handle food. Change in ability to retain food (vomits or regurgitates). Change in ability to find food. Change in interest in food (may have to do with sense of smell). Change in rate of eating. Change in completion of eating. Change in timing of eating. Change in preferred textures. Check only one in each category. Changes in frequency and accidents No change in frequency and no accidents. Increased frequency, no accidents. Decreased frequency, no accidents. Increased frequency with accidents. Decreased frequency with accidents. No change in frequency but accidents. Bladder control No change in urination control or behavior. Leaks urine only when asleep. Leaks urine only when awake. Leaks urine when awake or asleep. Full-stream, uncontrolled urination only when asleep. Full-stream, uncontrolled urination only when awake. Full-stream, uncontrolled urination when awake or asleep. No leakage or uncontrolled urination but in inappropriate or undesirable location. Bowel control No changes in bowel control. Defecates when asleep - formed diarrhea mixed Defecates without apparent awareness - formed diarrhea mixed Defecates when awake and aware of action but in inappropriate or undesirable locations - formed diarrhea mixed v 3-2-2015 Page 23 of 25
AGE-ASSOCIATED BEHAVIOR SCREEN (cont) Visual Acuity Auditory Acuity Interactions Sleep/Wake Cycle Check only one No change in visual acuity detected by behavior seems to see as well as ever. Some change in acuity not dependent on ambient light conditions. Some change in acuity dependent on ambient light conditions. Extreme change in acuity not dependent on ambient light conditions. Extreme change in acuity dependent on ambient light conditions. Blind. Check only one No apparent change in auditory acuity. Some decrease in hearing not responding to sounds the dog used to Extreme decrease in hearing have to make sure the dog is paying attention, repeat signals, go get the dog when called. Deaf no response to sounds of any kind. Check only one in each category Play/Toys No change in play with toys. Slightly decreased interest in toys. Slightly decreased ability to play with toys. Slightly decreased interest and ability to play with toys. Extreme decreased interest in toys. Extreme decreased ability to play with toys. Extreme decreased interest and ability to play with toys. Humans No change in interaction with people. Recognizes people but slightly decreased frequency of interaction. Recognizes people but greatly decreased frequency of interaction. Withdrawal but recognizes people. Does not recognize people. Other Pets No change in interaction with other pets. Recognizes other pets but slightly decreased frequency of interaction. Recognizes other pets but greatly decreased frequency of interaction. Withdrawal but recognizes other pets. Does not recognize other pets. No other pets or animal companions in house or social environment. Check only one No changes in sleep pattern. Sleeps more during the day. Some change awakens at night and sleeps more during the day. Much change profoundly erratic nocturnal pattern and irregular daytime pattern. Sleeps virtually all day, awake occasionally at night. Sleeps almost around the clock. v 3-2-2015 Page 24 of 25
FAMILIAL BEHAVIOR HISTORY If a pedigree is available and any familial behavior history is known, mark each family member - No known behavior information. KA Known affected. KU Known unaffected. TA Tentatively or possibly affected. TU Tentatively or possibly unaffected. AO Affected with another behavioral problem. No pedigree is available for this dog. Is a pedigree available? There is a pedigree available for this dog but it is not attached. Pedigree is attached. Are any family members known? Yes No If yes, describe. Are any known family members affected? Yes No Affected relatives do not have to have the same form of the condition to be considered affected. In other words, some dogs may lick themselves whereas others follow fences or chase their tails. If you know what other affected dogs do, describe. Which statement most accurately describes your feelings about the problem? I am here only out of curiosity. The problem isn t serious. I d like to change the problem but it s not serious. The problem is serious and I d like to change it but, if it remains unchanged, that s all right. The problem is very serious and I d like to change it but, if it remains unchanged, I ll keep my dog. The problem is very serious and I d like to change it and, it if remains unchanged, I ll euthanize or give up my dog. If considering rehoming or euthanasia, have you discussed this within the family? With the place where you obtained your dog? Is there anything else you think we should know? COMMENTS Attachments Floor plan for each residence. Primary vet medical record Primary vet laboratory results esp CBC, UA, chem screen, T4 (if ever done) v 3-2-2015 Page 25 of 25