Canine Behavior History Form - Indiana Veterinary Behavior

Today's Date *

Name *

First

Last

Preferred Pronouns

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Primary Email *

Do you wish to be contacted by phone or email?

Phone
Email

Name of Pet

Breed

Date of Birth/Age

Sex

Neutered or Spayed?

Neutered
Spayed
Not Fixed

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

Who were you referred to our clinic by?

(Please provide 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? Do you have any food allergies (ex. Nut Allergy)?

Behavior Problem

What is the primary behavior problem or complaint?

Additional problems (please list):

How frequently do the problem(s) occur? (how many times daily, weekly or monthly)

What are some good qualities about your dog?

Dog's Background

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?

Diet and Feeding

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:

Daily Schedule

Please briefly describe a typical 24-hour day in your dog's life and 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? If yes, what type of 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? Returning home?

Training

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 skills did you work on with the trainer or class?

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, animals or objects? If yes, whom or what does he or she mount?

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:

Low
Average
High
Excessive

Medical History

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

Place the above behavior codes next to each question:

Pet Dog *

Hug Dog *

Kiss Dog *

Lift Dog *

Call Off of Furniture *

Approach on Furniture *

Disturb While Resting/Sleeping *

Approach While Eating *

Take Dog Food Away *

Take Human Food Away *

Take Water Dish Away *

Take Bone/Chew *

Take Toy/Object *

Approach When Dog Has Toy/Object/Bone *

Verbally Punish *

Speak at Dog (normal tone) *

Bend Over Dog *

Approach Dog Near Spouse *

Enter Room *

Leave Room *

Reach Toward Dog *

Put Leash/Collar On or Off *

Bathe Dog *

Groom/Brush Dog *

Trim Nails *

Dog at Veterinary Hospital *

Response to “Sit" *

Response to “Down” *

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 *

(Please skip to the next 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? Please describe each bite incident in detail (if applicable) and the 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?)

Who is/are the target(s) of aggression?

Did your dog bite as a puppy, or growl/snap at a person? If yes, please describe the situation, and include age of your dog at the time:

Expectations

What are your goals for you and your dog with working with a veterinary behavior clinic? *

Any Additional Comments:

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.