Canine Behavior History Url General Information Client's Name * Address * ZIP Code * Home Phone Work/Day Phone Email Address * Pet's Information Name of Pet * Breed * Pet's Date of Birth * Sex * Male Female Neutered/Spayed * Yes No Regular Veterinarian - Doctor Clinic Name Clinic Address Clinic Phone Clinic Fax What is the main behavior problem or complaint? Additional problems (please list) Main Problem Frequency Other Problem Frequency Other Problem Frequency Chronology of the Behavior Problem When did you first notice the main problem (age of dog)? When did it first become a serious concern? In what general circumstances does the dog misbehave? Has this problem changed in frequency? Please describe. Has this problem changed in intensity? Please describe. Most recent incident Most recent incident date Second to last incident Second to last incident date Third to last incident Third to last incident date Other significant incidents What have you done so far to try to correct the problem? How do you discipline your dog for this and for other misbehavior? Home Environment People living in household, including ages of children. Please include name and hours away from home. Animals in household, including patient. Please include name, species, breed, sex, age obtained, and age now. In what sequence were the above animals obtained? What is your dog's relationship to the other animals? Please describe. What type of house do you live in? Please describe. What type of area do you live in? City/Town Suburbs Rural Have you moved since acquiring your dog? Yes No How many times have you moved? Has your household (people or animals) changed since acquiring your dog? Please describe. Have any humans or pets in the household recently been diagnosed with any medical conditions? If so, when? Dog's Background Why did you decide to get a dog? Why did you choose this breed? Where did you get this dog? SPCA Breeder - newspaper ad/flyer Breeder - referral Pet store Friend Stray Other Other source Have you owned dogs before? Yes No If known: littermate females If known: littermate males How many animals were there to choose from? Why did you choose this dog over the others? Was a temperament test performed? Temperament test result Describe your dog's behavior as a puppy Do you have any news about littermate behavior? Did you meet the parents? Please describe their behavior. Has this dog had other owners? Yes No How many other owners? Why was the dog given up? At what age was your pet neutered/spayed? Why was this done? Were there any behavior changes after neutering? If your pet is intact, has he/she ever been bred? Yes No Are you planning to breed? Yes No Unsure If you have an intact female, when was her last heat? Was it normal? Diet and Feeding What do you feed your dog? Please be specific, e.g. brand name. Has your dog's appetite increased, decreased, or had no change? How much do you feed? Please be specific. Meal Times Who feeds the dog? Location What treats do you feed your dog? What is your dog's favorite treat? Daily Schedule - Typical 24 Hour Day Please describe a typical 24-hour day in your dog's life. How does the dog behave with familiar visitors? How does the dog behave with unfamiliar visitors (children or adults)? How do you exercise your dog? Is the dog free in a fenced yard? How do you play with your dog? What toys does the dog have? Is your dog housetrained? Yes No How was the dog housetrained? Does your dog ever eliminate in the house? Yes No Urinate? Yes No Defecate? Yes No Where does your dog sleep at night? Does your dog sleep more, less, or the same? Area kept when family is at home Area kept when family is away Area kept when family is asleep Area kept when guests are visiting Behavior just prior to your departure Behavior just after your return Obedience Training What basic obedience training has your dog had? None Trained at home Started obedience classes but didn't finish Graduated obedience class once Graduated obedience class two or more levels Private trainer Other Other obedience training How old was the dog when obedience training started? Who in the family is the primary trainer? Does your dog have any awards or titles? Please describe. Has your dog had any hunting, herding, protection, attack or Schutzhund training? For each family member, what percent of the time does your dog obey sit, down, stay, come, and heel/don't pull? Does your dog know any tricks? Please describe. Have you exhibited your dog in breed shows? Yes No No, but I plan to Does your dog jump up on you or others without permission? Yes No Does your dog paw at you or at others? Yes No Does your dog lick you? Yes No Does your dog mount people? Yes No If yes, whom does he or she mount? Does your dog mount other animals or objects? Yes No Please describe mounting of other animals or objects. Does your dog ever bark at you? Yes No When? Please describe. 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, for this or other problems? Has your dog been on medication in the past? Date of most recent rabies vaccination Rabies vaccination type 1 year 3 year Aggression Screen Aggression Screen Owner Aggression Screen Pet Aggression Screen Date Please select GR (growl), SL (snarl/bare teeth), SB (snap/bite), NR (no reaction), or NA (not applicable) for each situation. 1. pet dog GR SL SB NR NA 2. hug dog GR SL SB NR NA 3. kiss dog GR SL SB NR NA 4. lift dog GR SL SB NR NA 5. call off furniture GR SL SB NR NA 6. push/pull off furniture GR SL SB NR NA 7. approach on furniture GR SL SB NR NA 8. disturb while resting/sleeping GR SL SB NR NA 9. approach while eating GR SL SB NR NA 10. touch while eating GR SL SB NR NA 11. take dog food away GR SL SB NR NA 12. take human food away GR SL SB NR NA 13. take water dish away GR SL SB NR NA 14. take rawhide GR SL SB NR NA 15. take biscuit/cookie GR SL SB NR NA 16. take real bone GR SL SB NR NA 17. take toy/object GR SL SB NR NA 18. approach when dog has any object/toy/bone GR SL SB NR NA 19. verbally punish GR SL SB NR NA 20. physically punish GR SL SB NR NA 21. visual threat GR SL SB NR NA 22. speak to dog (normal tone) GR SL SB NR NA 23. stare at dog GR SL SB NR NA 24. bend over dog GR SL SB NR NA 25. push on shoulders or back GR SL SB NR NA 26. approach dog near spouse GR SL SB NR NA 27. enter room GR SL SB NR NA 28. leave room GR SL SB NR NA 29. reach toward dog GR SL SB NR NA 30. leash restraint GR SL SB NR NA 31. collar restraint GR SL SB NR NA 32. scruff restraint GR SL SB NR NA 33. put leash on/take off GR SL SB NR NA 34. put collar on/take off GR SL SB NR NA 35. bathe dog GR SL SB NR NA 36. towel dog GR SL SB NR NA 37. groom/brush dog GR SL SB NR NA 38. dog at groomer's GR SL SB NR NA 39. trim nails GR SL SB NR NA 40. leash/collar correction GR SL SB NR NA 41. response to sit GR SL SB NR NA 42. response to down GR SL SB NR NA 43. dog at veterinary clinic GR SL SB NR NA 44. unfamiliar adult enters house or yard GR SL SB NR NA 45. unfamiliar child enters house or yard GR SL SB NR NA 46. familiar adult enters house or yard GR SL SB NR NA 47. familiar child enters house or yard GR SL SB NR NA 48. response to toddlers/babies GR SL SB NR NA 49. dog in car at tollbooths, gas stations GR SL SB NR NA 50. unfamiliar adult approaches owner, dog on leash GR SL SB NR NA 51. unfamiliar child approaches owner, dog on leash GR SL SB NR NA 52. dog in house, sees people outside GR SL SB NR NA 53. response to other dogs, while on leash GR SL SB NR NA 54. response to other dogs, while not on leash GR SL SB NR NA Problem Seriousness Where are you on a scale of 1 to 5? 1 - I am here only out of curiosity - problem is not serious. 2 - I would like to change the problem, but it is not serious. 3 - The problem is serious and I would like to change it, but if it remains unchanged that's all right. 4 - The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog. 5 - The problem is very serious and I would like to change it; if it remains unchanged I will have my dog euthanized or give him/her up. Aggression Towards People Skip this section if aggression is not the problem. Attacks are sudden and surprising Yes No Episodes appear unprovoked Yes No The dog is abruptly docile after an episode Yes No The dog appears sorry afterwards Yes No The dog appears disoriented afterwards Yes No Episodes are associated with a glazed or absent expression Yes No I can usually tell what will set off my dog Yes No The aggressive behavior is new and uncharacteristic Yes No Has your dog bitten and broken skin? Yes No Number of bites that broke skin Total number of bites Total number of episodes of aggression Describe typical episode If the dog is in the above situation 10 times, in how many of those times is aggression seen? 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? Yes No If yes, please describe, including age. How old was your dog the first time he/she growled at a person? What was the circumstance of the first growl at a person? How old was your dog the first time he/she snapped or bit at a person? What was the circumstance of the first snap or bite at a person?
