Behavior Medicine Division Consult Paperwork

Canine Consultation Questionnaire
Owner Information
Name:
Address /City and State/Zip code: / City, State/Zip code:
Home and Cell Phone: / Home: Cell:
Work Phone:
Email:
Referred by:
Basic Canine Information
Canine’s Name:
Age: / Age2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years
Breed & Color: / Breed: Color:
Sex: / Female Male
Spayed or Neutered: Age when performed: / Spayed Neutered Age2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years
Weight: / lbs kg
Date and Age when acquired (if known): / Date: Age2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years
Source: / Breeder Shelter Stray Rescue Other:
History prior to being in rescue (if applic.):
Has your dog been bred: If so age: / Yes No Age2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years
How much interaction did he/she have with people and other dogs in the first year of life:
Describe your dog’s personality:
Dr. Pike’s Notes:
Canine Medical History
Family Veterinarian / Clinic Name
Phone: / Primary Veterinarian: Clinic name:
Phone:
Date of last veterinary visit
Current/regular medications:
(Such as allergy/heartworm/herbal/over the counter/pain meds/supplements/flea tick,etc) / Dose= mg, mL, etc
Route administered= oral, topical, eyes, ears, etc
Frequency= once daily, twice daily, once monthly, etc.
Medication: Dose:
Medication: Dose:
Medication: Dose:
Medication: Dose:
Medication: Dose: / Route: Frequency given:
Route: Frequency given:
Route: Frequency given:
Route: Frequency given:
Route: Frequency given:
Has there been any change in:
Drinking-
Eating- / Yes No Details:
Yes No Details:
Have you noticed any lumps, bumps, pain or limping:
Lumps or bumps-
Pain or limping- / Yes No Details:
Yes No Details:
Have you noticed any of the following: / Coughing Sneezing Vomiting Diarrhea
Has your dog ever been treated for their behavior in the past? If so, describe treatment and medication (if applicable): / Yes No If so, describe treatment:
Medications: Dose:
Medications: Dose:
Medications: Dose:
Medications: Dose:
Does your pet have or ever had any seizures: / Yes No
Dr. Pike’s Notes:
Current Members Dwelling in the Home
Yourself: / Age: / Occupation:
Other Household Pets
Have you owned dogs previously? / Yes No As an adult As a child
Have you owned this breed of dog previously? / Yes No
Have you owned other pets previously? / Yes No
Current pets in the householdType and Breed / Name / Age / Spayed or Neutered / Relationship with Patient (fight, play, avoid)
Yes No
Yes No
Yes No
Yes No
Training and Obedience
Has your dog ever attended Training Class:
Provide details: / Yes No Age of dog at training:
Trainer name/facility:
What types of training techniques were used:
How well did your dog do in class?
If asked to leave, explain why: / Very well Average Poor
How would you rate their learning ability: / Good Average Poor
What task does your dog perform regularly and reliably on command: / Sit Stay Down Fetch
Other:
Does your dog pull when on a lead: / Yes No Sometimes
How do you correct your dog when he/she misbehaves:
What types of training aides have you used (pinch collar, prong collar, electric shock…):
Dr. Pike’s Notes:
Diet and Feeding Habits
Type(s) of Food:
Brand(s): (i.e.: Nutro, Eukanuba, Alpo…) / Dry Can Both
Brand(s): Percentage of protein % (on pkg)
Where is the dog fed in relation to other dogs in the household: / Next to each other Across the room shared bowl
In separate rooms or crates
Is the dog protective of their food (growl, snap or bite)?
If so, provide details: / Yes No
Details:
Describe your dog’s appetite:
What speed do they typically eat at: / Good Average Poor
Fast Slow
Do you have to be present for your dog to eat? / Yes No
Do you add any supplements to their diet? If so, provide details: / Yes No
Details:
Does your dog have any allergies to food? / Yes No
Dr. Pike’s Notes:
Daily Activities
Where does your dog sleep:
Does your pet ever wake you at night?
If yes, how often and any idea why: / Yes No
How often:
When does your dogget to go outside and how long do they like to stay out for: / When:
How long:
How does your dog ask to go outside:
Does your dog roam free in the yard:
If fenced what type of material: / Yes No
Vinyl Wood Chain Link Other
Does your dog run the fence-line barking?
If yes: / Yes No
Other dogs At people
What type of exercise does your dog receive:
If other, provide details: / Walk Run Agility Training Other
Details: Frequency:
Is this done on or off a lead: / On Off
Is there any specific time devoted to play or training on a daily basis: / Yes No
What types of toys does your dog play with:
If other, provide details: / Balls Bones Ropes Frisbee Other
Details:
Where does your dog stay during the day when no one is home: / Crate Specified Room Free Run (in house)
Free Run (fenced)
Doggie daycare/camp
What does your dog do as you prepare to depart: /
Details:
Does your dog bark or whine as you are leaving? / Yes No
Typically, how long is your dog left alone without people on any given day:
Does your dog ever vocalize, engage in destructive behaviors, urinate or defecate while you are gone: / Vocalize Destructive behaviors
Urinate Defecate
Has there been any change in your household routine (new baby, new work hours…)?
If yes, provide details: / Yes No
Details:
Dr. Pike’s Notes:
Interaction With Family Members
What type of home do you have:
If other, details: / Apartment House Condo Townhome
Other Details:
What areas of your home does your dog have access to (ie-do you block access at all?):
Reaction to handling –
Is there any aggression in the following circumstances? This can include growling, snarling, lunging, nipping, snapping, showing teeth, or even biting. If biting please describe tear, puncture or bruising
Fill out the following tables depicting your canine’s typical reaction:
In each box, , describe the typical type of aggression (growling, snarling, etc) shown
Adult Owner #1
Name: / Adult Owner #2
Name: / Children / Any other specific individual
Name:
Handling/ Grooming / Yes No
NA / Yes No
NA / Yes No
NA
Petting or hugging / Yes No
NA / Yes No
NA / Yes No
NA
Disturbed when resting / Yes No
NA / Yes No
NA / Yes No
NA
Disciplining / Yes No
NA / Yes No
NA / Yes No
NA
Walking on the lead / Yes No
NA / Yes No
NA / Yes No
NA
Taking food away / Yes No
NA / Yes No
NA / Yes No
NA
Taking other objects / Yes No
NA / Yes No
NA / Yes No
NA
Dr. Pike’s Notes:
Interaction With Others
How does your dog behave when visitors come to the house (i.e. – barking, door charging):
Is the behavior different towards familiar and unfamiliar people?
If yes, provide details: / Yes No
Details:
Does your dog display aggression (growling, snarling, snapping, biting) to visitors inside your home?
If yes, provide details: / Yes No
Details:
Has your dog ever bitten or attacked anyone?
If yes, how many: / Yes No
Details:
Are there any regular visitors to the home: If so, provide the information requested: / Name:
Purpose:
Time & Days:
Dog’s Reaction:
Name:
Purpose:
Time & Days:
Dog’s Reaction:
What is your dog’s response to:
Frequent visitors:
Occasional visitors:
Rare visitors: /
Frequent:
Occasional:
Rare:
Canine’s reaction / Inside the home / Outside the home
Unknown men / Details: / Details:
Unknown woman / Details: / Details:
Unknown children / Details: / Details:
Unknown dogs:
On lead
Off lead (ie- dog park) / Details:
Details: / Details:
Details:
Other animals (cats, squirrels etc.) / Details: / Details:
Crowds/busy areas / Details: / Details:
Dr. Pike’s Notes:
Other Behaviors
Does your dog show inappropriate mounting or other sexual activity: / Yes No
To whom or what:
Is your dog protective over parts of his/her body (i.e. ears, mouth or feet): / Yes No
If yes, which regions:
Does your pet lick or chew him/herself more than you would expect? / Yes No
Does your dog display any reaction to noises such as thunderstorms or fireworks?
If yes, describe: / Yes No
Details:
Are there any other behaviors you find objectionable, feel you should mention or wish to discuss?
If yes, describe: / Yes No
Details:
Dr. Pike’s Notes:
The Current Problem
Describe the problem you are experiencing with your dog:
How old was the dog when it began:
Is this a chronic (constant) or intermittent problem: / Chronic Intermittent
Where does the problem commonly occur:
With whom:
How often:
If house soiling, does it occur when you’re: / Home Away Both
If destructive, does it occur when you’re: / Home Away Both
Additional details surrounding the problem:
Is there any legal action pending because of this pet? / Yes No
If yes, please explain in detail
Dr. Pike’s Notes:
Aggression Section (if applicable)
Describe the most recent incident and the setting it occurred in (be precise):
What was the dog’s body posture (position of ears, tail, face, hair on back):
What was your reaction or response:
What was the dog’s reaction to your response:
Was there any punishment? If so, what: / Yes No Punishment:
Was there a bite wound: / Puncture Tear
Prior to this incident, describe the previous three incidents: / 1
2
3
How frequently does this type of incident occur: / Multiple times a day Daily
Several times a week Weekly
Monthly Other:
What has been done to correct the problem:
Is the problem getting: / Better Worse No Change
Do you suspect any cause:
Dr. Pike’s Notes:
Relationship with Canine
How would you describe your/family’s relationship with this dog: / Adult Owner #1
Adult Owner #2
Children
What are your/family’s feelings about the dog’s present behavior: / Adult Owner #1
Adult Owner #2
Children
What is your expectation for change:
Under what circumstances would you consider re-homing this dog to someone:
Under what circumstances would you consider relinquishing the dog to a shelter or rescue:
Under what circumstances would you consider euthanasia:
What are your goals for treatment?
Dr. Pike’s Notes:
Videos
Videos of the specific problem behaviors are extremely helpful to verify your descriptions. Do NOT place any person or animal in danger just for the sake of getting videos. Feel free to bring the videos with you (on your phone, tablet, lap top etc) to your consultation. Please do not email videos ahead of time.
VIDEO Number: / Describe the scenario seen in the video:
#1
#2
#3
#4
#5
Veterinarian Notes:
1