Behavioural History Form Please complete this form with the copy of Completed Veterinary referral form & return to Gemma Prior to your consultation by post or email. Gemma Stephen BSc (Hons) 12 Revesby Ave Grimsby DN34 5JW gemma@natureswhisper.co.uk NOTE: This form is to be filled in by the person who spends most time with the dog. Please answer all questions honestly & with as much detail as possible. Videos, photos & floor plans for descriptions are welcomed but are not compulsory. Name: Address: Post Code: Phone: Email: Veterinary Surgery your dog is registered: Practice Vet: Address: Post Code: Phone: Email: Did somebody at your vet surgery refer you to me? Please state full name & position: Gemma Stephen, Natures Whisper: Dog Behaviour Grimsby 2015 Page 1
Where did you find Natures Whisper if it was not via your veterinary surgery? (If it was an internet search please explain where e.g. google, thisisgrimsby, website etc) Have you had dogs before? If so what breed & temperaments? Ever done any training before with previous dogs? Describe your ideal dog here: ABOUT YOUR DOG Name: Current age: Birth date: Obtained from: Last Vaccination date: Insured: Breed: Rescue/ Rehome (when & where): Dogs History: If dog is a rescue please note what you have been told so far. If owned from puppyhood please summarize early socialisation experiences (what where they exposed to & how dog responded) / positive & negative experiences between date obtained to 6months. Sex: Male / Female Neutered: Entire: (Please include age neutering occurred) Diet & Brand of food: Gemma Stephen, Natures Whisper: Dog Behaviour Grimsby 2015 Page 2
Describe Dogs Personality / temperament e.g. nervous, over excitable etc Is your dog on medication? Is your dog/ has your dog been on medication for behaviour in the past? Please discuss. How would you rate your dogs response & reliability to the following: Commands Please Circle or Mark with a X Sit I don t know Rarely Sometimes Ok/ Usually Always Perfect Lay Down I don t know Rarely Sometimes Ok/ Usually Always Perfect Stay/ Wait I don t know Rarely Sometimes Ok/ Usually Always Perfect Come I don t know Rarely Sometimes Ok/ Usually Always Perfect Leave it I don t know Rarely Sometimes Ok/ Usually Always Perfect Heel I don t know Rarely Sometimes Ok/ Usually Always Perfect Settle I don t know Rarely Sometimes Ok/ Usually Always Perfect No I don t know Rarely Sometimes Ok/ Usually Always Perfect Describe Your Main Concerns: (if more than one problem please list with numbers) Do you feel these main concerns are: Mild Moderate Serious Extremely Serious Date First Noticed How Long has it occurred When, where & whom did it begin with or does it present with? How many times does the behaviour occur in 24hrs? How long does the behaviour present at each time? Gemma Stephen, Natures Whisper: Dog Behaviour Grimsby 2015 Page 3
What has been done so far to handle it? How do you react? How does the dog react to your reaction? Does your dog have any known fears & dislikes? How does your dog react to the following: Unknown Male Humans On lead Off Lead In the home Unknown Female Humans Unknown Children Known Male Humans Known Female Humans Known Children Unknown Dogs Known Dogs Gemma Stephen, Natures Whisper: Dog Behaviour Grimsby 2015 Page 4
What do you want to achieve? How do other family members feel about the dog & its behaviour? Has your dog ever suffered any trauma has your dog ever been hurt or attacked by another dog or person? Describe your dogs typical 24hr daily routine: Does your dog sleep well at night? Does your dog Sleep the whole night? Does your dog sleep in the day? Does your dog treat all members of the household the same way? Please discuss How is your dog when it is handled all over? How does your dog behave with the vet? Please list your dogs toys & chews that it has available Are they available all day everyday? Gemma Stephen, Natures Whisper: Dog Behaviour Grimsby 2015 Page 5
What are the favourite toys or games to play? How do you correct your dog when it misbehaves? How do you reward your dog when it behaves? AGGRESSION Please discuss the scenario of the dogs aggressive outburst or incident? E.g. what was happening prior to, during & after, who was present what where there reactions how did the victim react? Are there common triggers you have noticed set your dog off? Are there any warning signals from your dog? What is your reaction during these times? What are the reactions of others? What the dogs response to yours & other reactions to it? Describe the bite? E.g. air snap, muzzle punch, puncture wounds, scratches, tears, how deep is the wound, how many wounds, how many bite points Gemma Stephen, Natures Whisper: Dog Behaviour Grimsby 2015 Page 6
YOUR HOME Type of home: e.g. flat, bungalow etc Dogs Access in the home? Where they can and cannot go? List other pets here: names, breed, species, sex, age. List who lives in the house & ages: What are your occupations? EXTRAS Is there any other information which you believe I should know to aid your case? I agree that the above information is true to the best of my knowledge. I give full permission for Gemma Stephen to advise & perform dog behaviour modification training on my dog & all relevant house members will be present to be taught where possible. I agree that progression & monitoring is a part of behaviour modification & I agree that a review consultation is compulsory after my initial consultation to review progress, this is to be taken within approx 1 month of my initial consultation date. I understand that if I cancel & do not reschedule this review session I am required to still pay 50% of the full consultation fee & provide an email or phone call describing progress made so far to keep reports up to date. I take full responsibility for my dog & any final decisions regarding them, however I am fully aware that the advice & knowledge from Gemma Stephen is for the best intentions for the welfare of my dog & those who have regular contact with my dog & members of the public & I take full responsibility if for any reason I deviate or change from the advice given. I am also aware that the use of inhumane equipment, punitive methods/ dominance, pack leader techniques are prohibited in Gemmas training, this includes the use of inhumane training equipment such as choke chains, prong collars, electro collars, hitting, whipping, pinching & pinning down. If I use any of the punitive methods which Gemma deems inhumane after she has advised the implications & dangers of using such methods/ equipment, will result in the cessation of consultations without refund. I understand that my details will not be given or passed on to any third parties & confidentiality of my case is enforced. I do however give full consent for Gemma Stephen to submit a behavioural report of my case & details to my veterinarian when required. I understand that Gemma Stephen is a qualified canine behaviourist & is not a qualified veterinarian & does not replace the advice & treatment of medical professionals & communication between Gemma & my Vet is necessary. I understand that Gemma recommends that even herbal/ homeopathic supplements to aid behaviour should also be initially discussed with my vet to check it is acceptable before purchasing, even if I do not purchase them from my vet. I agree to Gemma s 42hr cancellation policy, that cancellations made with 42hrs notice of your booking date are free of charge but those cancellations made under 42hrs from the booking date, regardless of the emergency or reason for cancellation will require a payment of 50% of the full consultation charge of the booking made. I confirm that I have read & agree to all of these terms & conditions. If sending via email please mark with an X in this box only: (The marking of this X gives my official electronic signature in agreement to all above in replacement of my actual written signature) DATE: If sending via post Print name: Signature: Gemma Stephen, Natures Whisper: Dog Behaviour Grimsby 2015 Page 7