NYC Veterinary Specialists
E’Lise Christensen, DACVB
410 W 55th Street, New York, NY 10019
Phone: 646-434-1361 Fax: 646-434-1361
Email:
CANINE BEHAVIOR FORM
Client Information: Patient Information:
Name: ______Name:______
Address: ______Breed:______
______DOB/Age:______
Zip Code: ______Sex: ______
Home Phone:______Neutered/Spayed: Yes______No______
Work Phone:______
Cell/Alternate:______
Email: ______
Who is your regular Veterinarian?:
Dr. Name: ______
Clinic Name:______
Address:______
______
Phone: ______
Fax: ______
BEHAVIOR PROBLEM
Please describe the main problem you are having with your dog:
Please describe any other behavior problems that your dog exhibits:
Please rank the above problems from most distressing to least distressing:
1)
2)
3)
What is your favorite time to be with your dog?
What is your favorite activity that you share with your dog?
What is the best behavior that your dog performs?
Please describe in detail the two most recent events and the very first event that you remember.
Most recent event:
Date:
Time of day:
Who was present?
What occurred?
What was your dog’s body language during the event (i.e. tail up or down, ears up or back, etc.)?
How did you respond to the event?
Were there any injuries during this event? If so, who was injured and what was the extent of the injury?
Next most recent event:
Date:
Time of day:
Who was present?
What occurred?
What was your dog’s body language during the event (i.e. tail up or down, ears up or back, etc.)?
How did you respond to the event?
Were there any injuries during this event? If so, who was injured and what was the extent of the injury?
Please describe any other significant events:
How many times per day do you note the most concerning behavior?
Has this problem changed in intensity?
Has this problem changed in frequency?
What have you tried to correct this problem?
What techniques do you use to discipline your dog for this behavior and other problems?
HOUSEHOLD
Please list the people in your household including ages of all people, occupations, relationship to each other, and hours away from home.
Name Age Occupation Relationship Hours away from home
1)
2)
3)
4)
How old was your dog when you obtained him/her?
Please list the other animals in the household from most recent addition to first animal obtained.
Animal Name Species Breed Age at adoption Age now
1)
2)
3)
4)
In what sequence were the above animals obtained?
What is your dog’s relationship with the other animals (i.e. friendly, hostile, fearful)? Please describe.
In what type of area does you dog spend most of his/her time? City/Town Suburbs Rural
In what type of house/apartment does your pet spend most of his/her time?
Please draw a floor plan of each level of the main residence below.
Does your dog spend time at a secondary residence or vacation home? Yes No
If yes, please describe the location and floor plan of this home:
Does your dog travel frequently? Yes No
If yes, please describe method of travel and how this is tolerated:
Have you moved since acquiring your dog? Yes No
If yes, how many times?
Has your household (people or animals) changed since acquiring your dog? Yes No
If yes, please describe:
DOG’S BACKGROUND
Why did you decide to get a dog?
Why did you choose this breed?
Where did you get this dog? SPCA/shelter Breeder- newspaper ad/flyer Breeder- referral Pet store Friend Stray Other:______
Have you owned dogs before? Yes No
If known: how many littermates? _____M ales _____ Females
How many animals did you choose from?
Why did you choose this dog over the others? Please be specific.
Was a temperament test or behavioral evaluation performed? Yes No Unknown
If yes, please describe the results:
If Applicable, describe your dog’s behavior as a puppy
Do you have any news about littermate behavior? (please describe)
Did you meet the parents? Yes No, please describe their behavior:
Has this dog had other owners? Yes No, how many?
Why was the dog given up? ______
At what age was your dog 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?
Brand name______Amount______Time of day fed______Protein % of diet______%
Has your dog's appetite (increased, decreased, no change)? ______
Who feeds the dog? Location ______
List your dog’s five favorite treats from most favorite to least favorite (including any human food treats that your dog likes):
1)
2)
3)
4)
5)
How often do you give treats?
List the top 5 non-food rewards that your dog enjoys:
1)
2)
3)
4)
5)
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?
Is the dog tied outside? Yes No
Does the dog run free?
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 Defecate
Where does your dog sleep at night (please be specific):
Where is his/her favorite sleeping spot?
Does your dog sleep (more, less, same)? ______
Have you ever used a crate to confine your dog? Yes No
If yes, what was your dog’s reaction?
Do you still use the crate? Yes No, why and when did you stop?
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?
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 ______
How old was the dog when obedience training started? ______
Type of training collar used / Trainer’s name (if applicable) / Dog’s response / Response, Rate 1-5: 1 = good; 5 = poorNone, trained off leash
Neck collar Y/N If yes, indicate type:
Remote collar Y/N If yes, indicate type (shock, citronella, etc.
Head halter Y/N If yes, indicate type:
Body harness Y/N If yes, indicate type:
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? Yes No
What per cent of the time does your dog obey the following commands, for each member of the family:
Family Member / Sit / Down / Stay / Come / Heel (Don't Pull)
Will your dog settle or relax on command? Yes No
How would you describe the training you tried with your dog? Reward-based Assertive/Domineering Aversive/mostly corrections Other:______
Briefly describe the training techniques:
What training was the most successful?
What training was the least successful?
Does your dog know any tricks? Please describe:
Have you ever used any of the following for punishment or training?
1) Physical punishment Yes No If yes, describe reaction:
2) Noise punishment (shaker can/siren) Yes No If yes, describe reaction:
3) Ultrasonic Yes No If yes, describe reaction:
4) Water sprayer Yes No If yes, describe reaction:
5)Verbal reprimands Yes No If yes, describe reaction:
6) Muzzle grasp Yes No If yes, describe reaction:
7)Pinning/alpha roll Yes No If yes, describe reaction:
8)Time-out Yes No If yes, describe reaction:
9)Booby traps/repellents: Yes No If yes, describe reaction:
What punishment is the most effective for your dog?
Does any punishment make the problem worse? Yes No If yes, describe:
Has punishment ever led to threatening behavior or aggression? Yes No Describe:
Does your dog respond differently to punishment from different family members? Yes No If yes, describe:
Have you exhibited your dog in breed shows? Yes No 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:
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
Has your dog ever been ill or injured in the past? Yes No If yes, please describe:
Problem Date began Date Resolved Medications and doses used
1)
2)
3)
Has your dog ever been diagnosed with a seizure disorder? Yes No
Does your dog have problems with his skin or ears (scratching, redness, greasy, hair loss, etc.)? Yes No
Has your dog been diagnosed with any bone or muscle problems? Yes No
How many times per week does your dog vomit or have diarrhea? ______ None
Does your dog have chronic sneezing or coughing? Yes No
Please describe any medications that have been used for past medical problems:
Medication Dose Frequency Date Began Date Ended Side effects noted
1)
2)
3)
4)
Please describe any medications that have been used for behavior problems in the past:
Medication Dose Frequency Date began Date ended Side effects noted
1)
2)
3)
4)
Date of most recent rabies vaccination: ______( 1 year, 3 year)
List any supplements that you have tried or that you are currently administering
Supplement Dose Frequency Date began Date noted Side effects noted
1)
2)
3)
4)
AGGRESSION SCREENING - (Owners-- Please Fill This Out Before Consult Even if Aggression is Not the Main Problem)
Owner: ______Pet: ______
Date: ______
GROWL / SNARL / SNAP/BITE / NO REACTION / N/A
1. pet dog
2. hug dog
3. kiss dog
4. lift dog
5. call off furniture
6. push/pull off furniture
7. approach on furniture
8. disturb while resting/sleeping
9. approach while eating
10. touch while eating
11. take dog food away
12. take human food away
13. take water dish away
14. take rawhide
15. take biscuit/cookie
16. take real bone
17. take toy/object
18. approach when dog has any object/toy/bone
19. verbally punish
20. physically punish
21. visual threat
22. speak to dog (normal tone)
23. stare at dog
24. bend over dog
25. push on shoulders or back
26. approach dog near spouse
27. enter room
28. leave room
29. reach toward dog
30. leash restraint
31. collar restraint
32. scruff restraint
33. put leash on/take off
34. put collar on/take off
35. bathe dog
36. towel dog
37. groom/brush dog
38. dog at groomer's
39. trim nails
40. leash/collar correction
41. response to "sit"
42. response to "down"
43. dog at veterinary clinic
44. unfamiliar adult enters house or yard
45. unfamiliar child enters house or yard
46. familiar adult enters house or yard
47. familiar child enters house or yard
48. response to toddlers/babies
49. dog in car at tollbooths, gas stations
50. unfam. adult approaches owner, dog on leash
51. unfam. child approaches owner, dog on leash
52. dog in house, sees people outside
53. response to other dogs, while on leash
54. response to other dogs, while not on leash
Please circle the number of the statement that most accurately describes your feelings about the problem.
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.
FOR AGGRESSION (TOWARDS PEOPLE)
Please answer yes or no to these characteristics of your dog's aggressive behavior:
______attacks are sudden and surprising
______episodes appear unprovoked
______the dog is abruptly docile after an episode
______the dog appears "sorry" afterwards
______the dog appears disoriented afterwards
______episodes are associated with a "glazed" or "absent" expression
______I can usually tell what will set off my dog
______the aggressive behavior is new and uncharacteristic
Has your dog bitten and broken skin? Yes No
Number of bites that broke 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?):