Preferred Pronouns Primary Phone * Primary Email * Do you wish to be contacted by phone or email? Name of Pet Breed Date of Birth/Age Sex Names of additional family members and ages in the household AND Names of additional pets in household (age, sex, breed) Who is your regular veterinarian? Clinic Name Did someone other than your vet refer you? If yes, who? What is the main behavior problem or complaint? Additional problems (please list): Please list all problems. How frequently do the problem(s) occur? (how many times daily, weekly or monthly) Please list other behavior problems not mentioned and severity: 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? If you obtained this dog as a puppy, how many dogs were there to choose from? Describe your dog's behavior as a puppy: Did you meet the parents? If yes, please describe their behavior: Has this dog had other owners? If yes, how many? At what age was your pet neutered/spayed? Were there any behavior changes after neutering/spaying? If your pet is "intact," has he/she ever been bred? 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: What is your dog's favorite treat? Please describe a typical 24-hour day in your dog's life (Please start with when your dog wakes up in the morning and identify times of day when the problem behaviors occur) How does your dog behave with familiar visitors? How does your dog behave with unfamiliar visitors (children or adults)? How do you exercise your dog? Is your dog free in a fenced yard? Is your dog house-trained? Where does your dog sleep at night? Where is your dog when alone in the house? Where is your dog when you have guests? How does your dog behave while you are leaving the house? How does your dog behave when you return? Has your dog ever attended a training class or had a trainer come to your home? If so, please give details (when, where, age of dog, who trained dog) What method of training was used (i.e. clicker training, leash corrections, special collars, etc.) Name of trainer? Please list all behaviors (sit, down, shake, etc.) that your dog has been trained to offer? Have you done any specialized training with your dog (i.e. agility, tracking, fly ball)? Have you consulted any other behavior specialists prior to your appointment with us? If so, who? 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. Does your dog jump up on you or others without permission? Does your dog paw at you or at others? Does your dog mount people? If yes, whom does he or she mount? Does your dog mount other animals or objects? If yes, please describe: Does your dog ever bark at you? If yes, when? Does your dog bark at other times? Please describe: What is your dog's activity level in general: Is your dog on any medication now? If yes, please list name, dosage, and frequency. Has your dog been on medication in the past? Please list any previously diagnosed medical problems and how they were treated. Date of most recent rabies vaccination? (1 year or 3 year) Aggression Screen
GR - growl
SL - snarl/bare teeth
SB - snap/bite
NR - no reaction
NA - not applicable
above behavior codes next to each question: Disturb While Resting/Sleeping Approach When Dog Has Toy/Object/Bone Speak at Dog (normal tone) Dog at Veterinary Hospital Unfamiliar Adult Enters Yard or House Unfamiliar Child Enters Yard or House Familiar Adult Enters Yard or House Familiar Child Enters Yard or House Response to Toddlers/Babies Dog in Car at Gas Stations, Drive-thrus Unfamiliar Adult Approaches Dog on Leash Unfamiliar Child Approaches Dog on Leash Dog in House, Sees People Outside Response to Other Dogs While on Leash Response to Other Dogs While Not on Leash Aggression Towards People
(Please skip this section if aggression towards people is not the problem.) Please answer these characteristics of your dog's aggressive behavior: A. I can usually tell what will set off my dog? B. The aggressive behavior is new and uncharacteristic? Has your dog bitten and broken skin? Total number of bites (that did or did not break skin): Total number of episodes of aggression (growling, snapping, biting)? Describe typical episode (eg. does dog growl, lunge or bite, and in what circumstance?) If the dog is in one of the situations listed above 10 times, in how many of those times is aggression seen (eg. all=100%, just one=10%, etc.)? What parts of the body has the dog bitten, and how severe were the injuries? Who is/are the target(s) of aggression? Did your dog bite as a puppy? If yes, please describe, including age: How old was your dog the first time he/she growled or snapped at a person? What was the circumstance? What are your goals and expectations for your appointment with us? Any Additional Comments: 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? Please note: Your behavior history form was uploaded to the Veterinary Behavior of Indiana's email address once you get a confirmation page with a picture of a large dog.