Preferred Pronouns
Primary Phone *
Primary Email *
Name of Pet
Breed
Date of Birth/Age
Sex
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: *
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? Do you have any food allergies (ex. Nut Allergy)?
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? *
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?
Has this dog had other owners? If yes, how many?
Did you meet the parents? If yes, please describe their behavior:
Describe your dog's behavior as a puppy:
At what age was your pet neutered/spayed? Were there any behavior changes after neutering/spaying? *
Please list any current diagnosed medical problems: *
Is your dog on any medication now? If yes, please list name, dosage, and frequency. *
Please list any previously diagnosed medical problems and how they were treated. *
Was your dog on any medication previously? If yes, please list name, dosage and frequency. *
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 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?
What method of training was used (i.e. clicker training, leash corrections, special collars, etc.)?
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)?
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? *
How does your dog behave when you leave your home? *
Have you used a camera to watch your dog while they are home alone? *
How does your dog behave when you return from home? *
Does your dog exhibit a fearful response to sudden household noises (example: smoke detector), fireworks, or thunderstorms? *
If yes, what behavior(s) does your dog exhibit during these noise events? *
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 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 exhibit aggressive behavior over resources? *
If yes, what are the resources? (ex. Food, toys, human attention, etc.) *
Whom does your dog exhibit this behavior towards? (ex. Family members, other pets in home, etc.) *
How does your dog act when they see an unfamiliar person or child? *
Where is your dog when an unfamiliar person or child comes into your home? *
How does your dog act when they see an unfamiliar dog? *
How does your dog act when they see a familiar dog (non-housemate)? *
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, disturb 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. *
Can you usually tell what will sets off your dog? Is the aggressive behavior new and uncharacteristic? *
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:
