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Canine Behavior History Form
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Canine Behavior History Form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 9
Client Name
*
First
Last
Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient Name
*
Breed
*
Age
*
Gender
*
Male
Female
MEDICAL HISTORY
Is your dog spayed/neutered?
*
Yes
No
If yes, at what age was the surgery performed?
*
Reason for spay/neuter?
*
Routine
Attempt to modify behavior
Other
Were there any changes ofter the procedure?
*
Yes
No
Briefly describe your dog’s medical history:
*
Current medications (including preventives and any supplements):
*
Next
BACKGROUND INFORMATION:
When did you adopt your dog?
*
How old was your dog at the time of adoption?
*
Where did you get your dog?
*
Shelter
Rescue/Foster
Breeder
Other
Is this your dog’s first home?
*
Yes
No
How many previous homes?
*
Do you know why he/she was given up?
*
Which traits describe your dog as a puppy? Check all that apply.
*
Friendly
Outgoing
Shy
Fearful
Aggressive
Playful
Is this your first dog?
*
Yes
No
How did you select this particular dog over the others?
*
Describe the temperament of your dog’s mother. Check all that apply.
*
Friendly
Shy
Aggressive
Unknown
Describe the temperament of your dog’s father. Check all that apply. (copy)
*
Friendly
Shy
Aggressive
Unknown
Do you know the status of your dog’s littermates?
*
Next
HOME ENVIRONMENT
Describe your home:
*
single family house
town house/multifamily home
apartment/condo
other
Have you relocated since you’ve owned this dog?
*
Yes
No
Please list approximate date(s):
*
Please list all members of your household and include their age if under 18:
*
Describe your dog’s relationship to the other members of the household:
*
Please list all household pets in order adopted, including species, breed, gender, age, and age at adoption:
*
Describe your dog’s relationship to the other household pets:
*
Next
MANAGEMENT
How much time does your dog spend indoors?
*
Do you have a fenced yard?
*
Yes
No
Does your dog run unsupervised outdoors?
*
Yes
No
How often do you walk your dog?
*
How does your dog behave when you prepare to take him for a walk?
*
Comes eagerly
Neutral
Hides
Growls
Other
How does your dog behave when you prepare to take him for a car ride?
*
Comes eagerly
Neutral
Hides
Growls
Other
Where does your dog sleep at night?
*
Who wakes up first?
*
You
Your dog
Other
Where is your dog’s favorite resting spot when you are home?
*
Does your dog rest on your furniture?
*
Often
Sometimes
Never
Describe your dog’s favorite toys:
*
Describe any interactive games that you play with your dog and note frequency:
*
How often do you brush your dog?
*
Daily
Weekly
Occasionally
Never
How often does your dog groom himself/herself?
*
Occasionally
Excessively
Does your dog usually follow you from room to room?
*
Yes
No
Does your dog have free access to the house when you leave?
*
Yes
No
Please describe the type of confinement:
*
Crate
Gate
Closed door
Tie
Other
How does your dog behave when you prepare to leave home? Check all that apply.
*
No reaction
Looks “sad”
Hides
Pants
Paces
Salivates
Whines
Barks
Other
How does your dog behave when you return home? Check all that apply.
*
No reaction
Calm greeting
Brief excitement
Excited for > 10 minutes
Which of the following does your dog chew or scratch? Check all that apply.
Clothing
Trash
Doors
Window frames
Remotes
Furniture
Other
What do you feed your dog (brand and specific formula)?
*
How long have you been feeding this diet?
*
How much do you feed?
*
How many meals per day?
*
One
Two
Three
Food is left out at all times
Which family member(s) is/are responsible for feeding?
*
Location of food bowl:
*
Kitchen
Laundry
Basement
Other
When does your dog eat “table food”?
*
Special occasions
After you have eaten
While you eat
Never
Other
What are your dog’s favorite treats?
*
Please describe your dog’s overall activity level:
*
Excessive
High
Moderate
Low
Very Low
Please describe a typical 24-hour day in the life of your dog:Paragraph Text
*
Next
BEHAVIORAL DETAILS
Please describe your main behavioral concern:
*
Describe a typical episode:
*
The behavior occurs:
*
Daily
Weekly
Monthly
PLEASE ANSWER THE FOLLOWING QUESTIONS FOR THE MAIN PROBLEM
When did you first notice the problem?
*
Describe the earliest incident you can recall:
*
Describe the most recent episode (include approximate date):
*
Please describe several representative episodes. Include details such as date, your dog’s posture (tail, ears) and any vocalization such as barking or growling.
*
Has the frequency of the behavior:
*
Increased
Decreased
Remained unchanged
Has the intensity of the problem:
*
Increased
Decreased
Remained unchanged
Indicate any changes in the status of household pets that occurred within 3 months of the onset of the problem:
*
Additional pet(s)
Loss of pet(s)
Illness in pet(s)
Indicate any changes in the status of household people that occurred within 3 months of the onset of the problem:
*
New household member(s)
Loss of household member(s)
Pregnancy
Illness
Indicate any changes of employment status that occurred within 3 months of the onset of the problem:
*
New location
Working from home
Working remote
New work schedule
Any other changes that occurred within 3 months of the onset of the problem:
What measures have you taken to manage the behavior?
*
Please subjectively rate your perception of the main behavior problem:
*
The behavior is not serious, I am just curious
The behavior is a nuisance but tolerable
The behavior is a serious problem but I would keep my dog if the behavior persists
The behavior is not tolerable and I may rehome my dog if the behavior persists
The behavior is not tolerable and I may euthanize my dog if the behavior persists
Please briefly describe any additional behavioral problems or concerns you experience with your dog:
Next
AGGRESSION SURVEY
Does dog demonstrate aggressive behavior(s)?
*
Yes
No
What was the age of your dog and circumstances surrounding the first snap or bite?
*
How many bites required medical attention?
*
Who was bitten?
*
Which of the following has your dog bitten?
*
Hands
Arms
Legs
Face
Chest
Buttocks
Other
Is your dog’s aggression predictable?
*
Yes
No
Do the attacks appear unprovoked?
*
Yes
No
Is your dog docile afterward?
*
Yes
No
Is your dog disoriented afterward?
*
Yes
No
Does your dog appear sorry afterward?
*
Yes
No
Did you notice a glazed expression before/after the bite?
*
Yes
No
Next
SOCIAL INTERACTIONS
Describe your dog’s behavior toward familiar visitors to your home:
*
Growls
Barks
Snaps/Bites
Friendly
Shy
Hides
Other
Describe your dog’s behavior toward unfamiliar visitors to your home:
*
Growls
Barks
Snaps/Bites
Friendly
Shy
Hides
Other
Describe your dog’s behavior toward children who visit your home:
*
Growls
Barks
Snaps/Bites
Friendly
Shy
Hides
Other
Describe your dog’s behavior toward other dogs who visit your home:
*
Growls
Barks
Snaps/Bites
Friendly
Shy
Hides
Other
My dog mounts:
*
Household adults
Househould children
Guests
N/A
Mounting behavior occurs mainly:
*
During play
When scolded
During greetings
Other
N/A
My dog mounts other animals or inanimate objects:
*
Often
Occasionally
Never
My dog jumps on family members or other without permission:
*
Often
Occasionally
Never
My dog paws at family members:
*
Often
Occasionally
Never
My dog barks at family members:
*
Often
Occasionally
Never
My dog barks excessively:
*
Yes
No
Next
TRAINING
How many weeks/months were required to house train your dog?
*
Was a crate used?
*
Yes
No
How often does your dog urinate or defecate indoors in unacceptable locations?
*
Often
Occasionally
Never
How do you generally discipline your dog, and how does he or she respond?
*
Please describe any formal training your dog has undergone:
*
What type of training collars do you use?
*
Flat buckle
Martingale
Choke collar
Prong colla
Electronic collar
Head halter
Harness
Other
How does your dog respond to basic obedience commands, such as sit, come, stay, down, etc:
*
Most of the time
Sometimes
Occasionally
Rarely
Never
Does your dog respond to (check all that apply):
*
You
Other household adults
Household children
Next
REACTIVITY SURVEY
Please indicate how your dog responds to the following:
Thunder
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Rain
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Wind
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Fireworks
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Loud Conversations
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Telephone
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Sudden noises (car backfiring, dropping heavy object, etc)
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Vacuum cleaner
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Lawn Mower
*
No response
Hides
Follows me
Paces
Whines
Growls
Barks
Chases
Other
Petting
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Hugs/Kisses:
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Lifting/carrying
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Approach/petting while at rest
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Approaching while on furniture
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Calling off furniture
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Pulling off or otherwise physically removing from furniture
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Approaching while eating
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Touching while eating
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Taking away the food dish
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Taking away the water dish
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Taking away human food or treats
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Taking away rawhide or bone
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Approaching when your dog has a rawhide or bone
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Taking away a toy or other coveted object
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Approaching when your dog is near his/her favorite person
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When someone enters or leaves a room
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When stared at
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When spoken to
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When visually threatened
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When verbally punished
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When physically punished
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When commanded to sit or lie down
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When pushed into a sit or down
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When pushed on shoulders or rump
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When restrained by a leash
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When restrained by a collar
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When a leash is put on
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When a collar is put on
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When someone reaches for your dog
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When someone steps over your dog
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When your dog is toweled dry
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When brushed
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When bathed
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When nails are trimmed
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
With the veterinarian
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
With the groomer
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When an unfamiliar person enters your yard/house
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When an unfamiliar dog enters your yard/house
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When a familiar person enters your yard/house
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When on leash and a person approaches
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When on leash and a dog approaches
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When off leash and a person approaches
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
When off leash and a dog approaches
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
In your house when people or dogs pass
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
In the yard when people or dogs pass
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
In the car when people or dogs pass
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
In response to an infant or toddler
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
In response to a squirrel, cat, etc.
*
No response/positive response
Snarl
Growls
Snap
Bite
Barks
Other
Submit