Client's Name: *

First

Last

Phone

Email *

Patient Information

Pet's Name: *

Breed

Date of Birth or Age *

Sex *

Male
Female

Neutered/Spayed *

Yes
No

Date at which your pet was neutered or spayed: *

Where did you get your dog? *

How long have you had your dog? *

Has your dog had other owners? *

Yes
No

If so, how many other owners? *

If applicable, please explain why your dog was relinquished by the previous owners. *

Environmental Information

How many people in the household?

Has there been any significant change in your household’s routine or schedule in the past 3 months?

Yes
No

What are your goals for this appointment?

Are there any children in the house or who come to visit regularly? *

Yes
No

If you feel that the relationship of the patient with a particular person is important to the assessment and treatment of the problem for which you are bringing your dog, please describe.

Tell us about your pet's environment. Check all that apply.

How many play sessions does your dog get per day?

Do you have multiple pets? *

Yes
No

Does your pet: *

Sleep with your other pets
Groom (lick) your other pets
Play with your other pets

List the other animals in the household and describe their relationship with the patient. *

Medical History

Please describe any significant medical illnesses, treatments and the outcome.

What do you feed your pet? *

Does your pet have any allergies or food sensitivities? *

Please check all the previous treatments tried:

Does your dog lick (you, the floor, himself, other objects, other people) excessively?

Yes
No

Scientific studies have shown a strong connection between gut and brain health. Please answer the questions below regarding your dog's gastrointestinal tract health.

How often does your dog experience vomiting?

How often does your dog experience diarrhea?

How often does your dog experience constipation?

How often does your dog show signs of a decreased appetite?

How often does your dog show signs of excessive licking?

How often does your dog show signs of lip licking?

Behavior Problem Information

Please fill out the section below regarding your three top concerns about your pet's behavior.

List the first concern for which you are see seeking help *

Age at which problem 1 started:

Frequency of problem 1

List the second concern for which you are see seeking help *

Age at which problem 2 started:

Frequency of problem 2

List the third concern for which you are see seeking help *

Age at which problem 3 started:

Frequency of problem 3

Have you ever worked with a dog training professional with this pet?

Yes
No

Have you worked with a dog training professional with this pet in the past three months?

Yes
No

If you have worked with a dog trainer previously, please list the company and trainer name and what behaviors were taught. Include puppy classes. This helps us to know what behaviors and methods have been used thus far in training your dog.

Are you planning to continue to work with the dog training professionals listed above?

Yes
No

Sleep Behaviors

Does your pet sleep through the night?

Yes
No

Have you noticed any change in your pet’s sleeping patterns in the past 3 months?

Yes
No

Does your pet take naps during the day when you are home?

Yes
No

Aggression Screen

If your dog has shown aggression (biting, lunging, barking, growling), please fill out this section. If not, go to the next section.

Are there any people in your household or who regularly come to visit who are at greater risk if bitten?

Elderly
Children
Adults or children who have illnesses which would reduce healing or which would increase risk

Has your dog ever bitten a person? *

Yes
No

Number of bites?

Number of bites that broke the skin?

Number of bites that were reported to public health authorities?

Has your dog ever bitten a dog? *

Yes
No

Number of bites?

Number of bites that broke the skin?

Number of bites that were reported to public health authorities?

Has there been any legal action as a result of your dog's behavior? *

Yes
No

Who is your dog aggressive toward?

If you chose Other, please explain:

When is your dog aggressive? Check all that apply.

If you chose Other, please explain:

What does your dog look like when he is aggressive? Check all that apply.

If you chose Other, please explain:

What does your dog do when visitors enter the home? Check all that apply.

If you chose Other, please explain:

Please check all the previous treatments tried:

If you chose Other, please explain:

Please add any additional information that you would like to share about how, when or to whom your pet is aggressive.

Storms/Sounds

If your dog exhibits fear or anxiety during storms or loud noises please fill out this section. If not, go to the next section.

What sounds is your dog afraid of? Check all that apply.

If you chose Other, please explain:

What does your dog do when he hears a scary sound? Check all that apply.

If you chose Other, please explain:

How long does it take after a sound for your dog to calm down entirely?

If you chose Other, please explain:

Please add any additional information that you would like to share about your dog's reaction to scary sounds.

Separation Behaviors

If your dog exhibits anxiety or distress when left alone please fill out this section. If not, go to the next section.

Does your dog follow you around the house?

Yes
No

How does your dog react when you prepare to leave? Check all that apply.

If you chose Other, please explain:

How does your dog behave when you return? (check all that apply)

Calm but happy
Barking, whining, jumping for less than 1 minute
Barking, whining, jumping for 1-2 minutes
Barking, whining, jumping for 5 minutes
Barking, whining, jumping for less than 10 minutes
Barking, whining, jumping for less than 15 minutes
Barking, whining, jumping for more than 15 minutes
Other

If you chose Other, please explain:

Where is your dog when you are not home?

If you chose Other, please explain:

What does your dog do when you are not home? Check all that apply.

If you chose Other, please explain:

Does your dog exhibit the behavior every time that you depart?

Yes
No

Does your dog exhibit the behavior only when alone?

Yes
No

Does your dog exhibit the behavior when a particular person leaves, but not another?

Yes
No

Please add any additional information that you would like to share about your dog's anxiety or panic when you leave.

Anxiety/Distress in the car

If your dog exhibits anxiety or distress when riding in the car please fill out this section. If not, go to the next section.

Please check all that apply to your dog's behavior when riding in the car

Please add any additional information that you would like to share about your dog's behavior in the car.

Displacement/Compulsive behaviors

If your dog exhibits any of the behaviors below, please fill out this section. If not, go to the next section.

Does your dog do any of the following?

Stare at lights/shadows
Run in circles
Chase tail
Fly snapping

Please add any additional information that you would like to share about the behaviors listed above

Did someone recommend euthanasia before your visit to us?

Yes
No

Have you considered euthanasia before your visit to us?

Yes
No

Have you considered rehoming your pet before your visit to us?

Yes
No

Anything else that you would like to share with us about your pet?

Dog Behavior History Form