Preferred Pronouns
Primary Email *
Primary Phone *
Name of Pet *
Breed *
Date of Birth/Age *
Sex *
Who is your regular veterinarian? *
Clinic name? *
We may offer treats during the consultation. Please let us know if that is OK and if so, does your dog have any food allergy/ sensitivity? *
Names of all family members (ages) in the household: *
Names of additional pets in household (age, sex, breed), as well as the order of acquisition: *
What is the primary behavior problem or complaint? *
How frequently do the problem(s) occur? (how many times daily, weekly or monthly)
What are some good qualities about your dog? *
Why did you decide to get a dog?
How old was your dog when he/she was acquired and where was he/she acquired from?
Has this dog had other owners? If yes, how many?
Describe your dog's behavior as a puppy:
At what age was your pet neutered/spayed? *
Please list any current diagnosed medical problems: *
Is your dog on any medication (including behavior medications) now? If yes, please list the name, dosage, frequency AND response: *
Was your dog on any medication previously? If yes, please list name, dosage, and frequency. *
Please list any previously diagnosed medical problems and how they were treated. *
Date of most recent rabies vaccination? (1 year or 3 year) *
Have you consulted any other veterinary behavior specialists prior to your appointment with us? If so, who? *
What do you feed your dog? (Please be specific, e.g. brand name)?
What are the meal times, or is the bowl left out all day?
Does your dog finish each meal?
Location of meals:
Please briefly describe a typical 24-hour day in your dog's life and when the problem behaviors occur: *
How do you exercise your dog?
Is your dog free in a fenced yard? If yes, what type of fenced yard?
Is your dog house-trained?
Where does your dog sleep at night?
What equipment do you use with your dog (ex. type of collar(s), harness, muzzle, leash, etc.)? *
Has your dog worked with a trainer and if so, please provide the name of the trainer and/or facility?
What skills did you work on with the trainer?
What method of training was used (i.e. treat training, clicker training, leash corrections, prong collar, or electric collar, etc.)
Please list all behaviors (sit, down, shake, etc.) that your dog has been trained to offer?
Who in your family is the primary trainer?
Reinforcers are things your dog loves (like treats, toys, play, or even attention from you). Please list your dog's reinforcers in order of the value they hold for him/her with #1 being their absolute favorite.
Where is your dog when alone in the house? *
What does your dog do when he/she is home alone? *
Have you used a video to watch your dog while they are home alone? *
How often and how long is your dog left home alone? *
How does your dog behave when you return home? *
Does your dog exhibit a fearful response to any noises? *
If yes, what noises? *
If yes, what behavior(s) does your dog exhibit during these noise events (ex. Pant, shake, hide, bark, etc.)? *
Does your dog show any abnormal, or repetitive behaviors (example: spinning, light chasing)? *
If yes, what behavior(s) does your dog exhibit and what is the frequency/ duration? *
Does your dog jump on, mouth, or mount you or others without permission? When? *
Does your dog exhibit aggressive behavior over resources? *
If yes, what are the resources? (ex. Food, toys, human attention, etc.) *
If yes, what does your dog do (ex. growl, stiff stare, snap, etc.)? *
Whom does your dog exhibit this behavior towards? (ex. Family members, other pets in home, etc.) *
What does your dog do when they see an unfamiliar person or child? Please describe their behavior. *
Where is your dog when an unfamiliar person or child comes into your home? *
What does your dog do when they see an unfamiliar dog? Please describe their behavior. *
What does your dog do when they see a familiar dog (non-housemate)? Please describe their behavior. *
Does your dog exhibit aggressive behavior (growl/lunges/snarls/bare teeth/snap/bite) towards you or any of your family members when handled? *
If yes, in what circumstance? (example: petting your dog, trimming nails, handling/picking up, disturbing your dog while resting, putting on a collar/harness/leash, etc.) *
Has your dog ever shown any aggression towards another dog or cat in your home? If yes, describe in detail. *
Has there been an incident that has escalated into a fight between your pet and another dog or cat in your home? If yes, describe in detail. *
Has your dog bitten and broken skin on a person? *
Please describe each bite incident in detail and the total number of bites (that did or did not break skin): *
What are your goals for you and your dog with working with a veterinary behavior clinic? *
Any Additional Comments:
