Behavioral Consultation Form - North Deering Veterinary Hospital

Behavior Consultation Form

What is your dog’s major behavior problem?

About Your Dog

Where did you get this dog?(Required)

If you have your dog’s pedigree please bring it to the appointment

Has this dog had other owners?

Yes

If yes, how many?

Why was the dog given up (if known)?

Have you owned dogs before?

Yes

Have you owned other pets before?

Yes

What happened to your last dog?

Why did you choose this particular breed?

Why did you decide to acquire a dog?

How old was this dog when you acquired it?

If known, how many littermates? Please break down males and females.

How many animals did you have to choose from?

Why did you choose this dog over the others? (please be specific and tell us who chose the pet and why):

Was a temperament test performed?

Yes

Unsure

What was the result of the temperament test if it was performed?

Please describe your dog’s behavior as a puppy (happy, active, destructive, anxious etc – the more details the better):

Do you have any news about littermate behavior? If so, please describe:

Did you meet your dog’s parents?

Yes

If yes, please describe their behavior:

Is your dog housetrained?

Yes

How did you housetrain your dog?

Does your dog ever eliminate in the house?

Yes

If yes, does your dog:

Urinate

Defecate

Both

Where does your dog eliminate in the house?

How often does your dog eliminate in the house?

Your Dog's Home Environment

Please list the people, including yourself, living in your household — and mark with an asterisk (*) all who will be attending the consultation.

Please list their name, age, occupation, and hours away from home.

Please list anyone else who has regular contact with the dog:

Please list all of the animals in your household, including the one you are bringing in to see us.

Name, Species, Breed, Sex/Desexed. Please also indicate the sequence in which you obtained the animals in your household.

What is your dog’s relationship to the other animals in your home? (eg. friendly, hostile, fearful)

Please Describe

How would you describe your relationship with your dog?

Do you have any physical ailment(s) that influences your ability to interact with your dog?

Yes

What type of area do you live in?

City/Town

Suburbs

Rural

Do you rent or own your house?

Rent

Own

What type of house do you live in?

Apartment – studio or 1 bedroom

Apartment - 2+ bedrooms

Townhouse/Duplex/Attached house

House - Single Family

Other

Have you moved since acquiring your dog?

Yes

If Yes, how many times?

How long since the last move?

Has your household (people or animals) changed since acquiring your dog?

Yes

If Yes, please describe:

Your Dog's Medical History

At what age was your pet neutered/spayed?

Why was this done?

Were there any behavior changes after the surgery? (please describe)

Has your dog ever been bred?

Yes

Are you planning to breed?

Yes

Unsure

If you have an entire female, when was her last heat?

Has your dog had any medical problems in the past? (e.g. skin disease, gastrointestinal problems, etc.)

Yes

Has your dog been on any medication in the past?

Yes

If yes, please list all medications, what they were for, and when your dog was last dosed:

Does your dog have any current medical problems? (e.g. skin disease, gastrointestinal problems, etc.)

Yes

Is your dog on any medication now currently? (e.g. cortisone, anti-biotics, etc.)

Yes

If yes, please list all medications including dose and frequency, what they are for, and expected completion date:

Is your dog on any medication such as heartworm preventatives, flea preventatives? (i.e. Heartgard, Revolution, Frontline, Advantage, Proheart Injection)

Yes

If yes, please list all medications including dose and frequency

Is your dog on any medication now for its behavioral problem (including natural treatments such as Rescue Remedy, Bach Flowers, St John’s Wort, Tranquility, Tryptophan, Green Lipped Mussels, etc.)?

Yes

If yes, please list all medications including dose and frequency:

What response (if any) has there been to each medication?

Your Dog's Problems/Issues

Why are you seeking help/advice about your dog?

What has prompted your visit today?

What is the main behavior problem or issue?

Why is the behavior a problem?

Does your dog have any other problem behaviors (please list)

Why are these behaviors a problem?

How frequently does the problem (or problems) occur (i.e. how many times daily, weekly or monthly)?

Please describe how the problem developed over time (chronology):

When did you first notice the main problem?

When did it become a serious concern?

Why did it become a serious concern?

In what general circumstances does your dog show these behaviors?

Has this problem changed in frequency? (please describe)

Has this problem changed in intensity? (please describe)

Has this problem otherwise changed?

How has this problem otherwise changed?

Did the secondary problems develop at the same time?

To help us better understand your dog’s problem, please describe what occurs when the episodes happen. Try to include as much detail as possible such as where it took place, time of day, who was present, what happened, etc.

Any other significant incidents?

Do you leave your dog inside the house when you go out?

Yes

If yes, where is your dog when he is alone in the house?

Where is your dog when you have guests and why?

How does your dog behave when you are leaving the house?

How does your dog behave when you return?

Does the dog’s level of excitement reflect your length of absence (i.e. is he more excited the longer you are gone?)

How does your dog react to thunderstorms?

How does your dog react to fireworks?

Does your dog react to other noises? If so, which ones and how?

How does your dog behave with familiar visitors (e.g. friendly, wary, timid, aggressive)?

How does your dog behave with unfamiliar visitors, children or adults (e.g. friendly, wary, timid, aggressive)?

Does your dog jump up on you without permission?

Yes

Does your dog jump on other people without permission?

Yes

Does your dog paw at you?

Yes

Does your dog paw at other people?

Yes

Does your dog lick you?

Yes

Does your dog groom, lick or bite himself excessively?

Yes

Does your dog mount people?

Yes

If yes, whom does he/she mount?

Does your dog mount other dogs?

Yes

Does your dog mount other animals or objects?

Yes

If yes, please describe:

Does your dog ever bark at you?

Yes

When does your dog bark at you?

Does your dog bark at other times? (please describe)

What is your dog’s activity level in general?

Low

Average

High

Excessive

What have you done to try to correct the problem so far?

How successful have these measures been?

How do you discipline your dog for this or any other problem?

Do you feel that you may have contributed to the problem (e.g. feel guilty)?

What are your goals for treatment?

Do you feel your goals are achievable?

Your Dog's Training

What basic training has your dog had?

No training

Puppy class

Trained at home

Started obedience classes but did not finish

Graduated one class at obedience

Graduated 2 or more levels at obedience

Boarded for training

Other

How old was the dog when training started?

Why did you take your dog to obedience training?

Did you find it helpful? Why or why not?

Who in the family is the primary trainer?

How did your dog behave at training?

What sort of collar do you use?

Flat

Choker

Chain

Head Collar (eg Halti, Gentle Leader)

Other

Does your dog have any awards or titles? (please describe)

Has your dog had any hunting, herding, protection, attack or Schutzhund training?

How would you rate your dog’s responses to each of the following? Good (G), Fair (F) or Poor (P)

Family Member: SIT, DOWN, STAY

Does your dog know any tricks? (please describe)

Do you play with your dog?

Yes

How do you play with your dog?

What sort of toys does your dog have?

What is his favourite toy?

Can your dog ‘Fetch’?

Have you exhibited your dog in breed shows?

Yes

No, but I plan to.

Your Dog's Daily Schedule

Please describe your dog’s daily exercise, including the amount of time of each:

Leash Walks

Supervised Off Leash Walks

Unsupervised free roaming

Loose in the Yard

Playing Outdoors

Playing Indoors

Other: (describe)

Total Active time each day (on average):

What percentage of time does your dog spend indoors or outdoors?

Where does your dog sleep at night? (please be specific, ie outside, inside, in your bedroom, on your bed etc)

Please describe a typical 24 hour day in your dog’s life: i.e. time he gets up, time fed etc.

Your Dog's Diet and Feeding

Who feeds your dog?

Where do you feed your dog?

Does your dog have any food allergies?

What do you feed your dog? (Please be specific with brand name)

How much do you feed? (Please be specific)

What times do you feed your dog?

Does your dog eat all the food you give at once?

Yes

If not, how long do you leave it down?

Where is your dog when you eat?

What is your dog’s favorite food treat(s)?

Do you feed your dog table scraps?

Yes

If yes, do you feed scraps from the table?

Yes

Which of these statements apply to you?

Do you have any other comments?

Please note any other information that you feel may be relevant to this problem.

Personality Screen

Please rate your dog’s personality using the Monash Canine Personality Questionnaire.
Please rate how well each word describes your dog’s personality by marking the appropriate box.
1 = really does not describe my dog,
6 = really describes my dog

Friendly

Persevering

Nervous

Energetic

Attentive

Easy Going

Independent

Trainable

Non-aggressive

Hyperactive

Submissive

Determined

Relaxed

Tenacious

Timid

Biddable

Active

Intelligent

Sociable

Restless

Fearful

Obedient

Lively

Reliable

Assertive

Excitable

Aggression Screen

**PLEASE SKIP THIS SECTION IF AGGRESSION IS NOT A PROBLEM**

Has your dog bitten other dogs?

Yes

Has your dog bitten other animals?

Yes

Has your dog bitten adults?

Yes

Has your dog bitten children?

Yes

Has your dog bitten and broken skin?

Yes

Number of bites that have broken the skin?

Total number of bites (that did or did not break the skin)

Total number of episodes of aggression (growling, snapping, biting)

Describe a typical episode: (eg does the dog growl, lunge or bite, and in what circumstances)

If the dog is placed in the above situation 10 times, how many of those times is aggression seen? (eg all = 100%, just one=10%)

What parts of the body has the dog bitten and how severe were the injuries?

Who is/are the targets of the aggression?

Did your dog bite as a puppy?

Yes

If yes, please describe, including at what age:

How old was your dog the first time he barked at a person?

What was the circumstance?

How old was your dog the first time he barked at another animal/dog?

What was the circumstance?

How old was your dog the first time he growled at a person?

What was the circumstance?

How old was your dog when he first growled at another dog/animal?

What was the circumstance?

How old was your dog when he first snapped or bit at a person?

What was the circumstance?

How old was your dog when he first snapped at or bit at another animal/dog?

What was the circumstance?

Please answer Yes or No to these characteristics of your dog’s aggressive behaviour:

Attacks seem sudden and surprising

Yes

Episodes appear unprovoked

Yes

The dog is abruptly docile after an episode

Yes

The dog appears ‘sorry’ afterwards

Yes

The dog appears disoriented afterwards

Yes

Episodes are associated with a ‘glazed’ or ‘absent’ look

Yes

I can usually tell what will set my dog off

Yes

The aggressive behaviour is new and uncharacteristic

Yes

Aggression Screen - Part 1

Please complete the tables below indicating how your dog would react when faced with each scenario. If your dog does not encounter any of the scenarios (i.e. you have never tried taking a toy from him/her) you should just tick Not Applicable – DO NOT TEST YOUR DOG if you are unsure.

How does your dog react to YOU when you do the following? DO NOT TEST YOUR DOG

Pat Dog

Hug Dog

Kiss Dog

Lift Dog

Call Off Furniture

Push/Pull Off Furniture

Approach On Furniture

Disturb whilst resting/sleeping

Approach whilst eating

Touch whilst eating

Take dog food away

Take human food away

Take water dish away

Take rawhide/pigs ear

Take dog biscuit

Take real bone

Approach when dog has a toy/bone

Verbally punish

Physically punish

Visual threat

Speak to dog (normal tone)

Stare at dog

Bend over dog

Push on shoulder or back

Approach dog near spouse

Approach dog near children

Enter room

Leave room

Reach towards dog

Leash restraint

Collar restraint

Scruff restraint

Put leash on/take off

Put collar on/take off

Bathe dog

Towel dog

Groom/brush dog

Trim nails

Leash/collar correction

Response to ‘Sit’

Response to ‘Down’

Aggression Screen - Part 2

How does your dog react if a STRANGER did the following? DO NOT TEST YOUR DOG

Pat Dog

Hug Dog

Kiss Dog

Lift Dog

Call Off Furniture

Push/Pull Off Furniture

Approach On Furniture

Disturb whilst resting/sleeping

Approach whilst eating

Touch whilst eating

Take dog food away

Take human food away

Take water dish away

Take rawhide/pigs ear

Take dog biscuit

Take real bone

Approach when dog has a toy/bone

Verbally punish

Physically punish

Visual threat

Speak to dog (normal tone)

Stare at dog

Bend over dog

Push on shoulder or back

Approach dog near spouse

Approach dog near children

Enter room

Leave room

Reach towards dog

Leash restraint

Collar restraint

Scruff restraint

Put leash on/take off

Put collar on/take off

Bathe dog

Towel dog

Groom/brush dog

Trim nails

Leash/collar correction

Response to ‘Down’

Response to ‘Sit’

Response to ‘Down’

Aggression Screen - Part 3

How does your dog react to the following? DO NOT TEST YOUR DOG

At the groomers

At the vet clinic

Unfamiliar adult enters house/yard

Unfamiliar child enters house/yard

Familiar adult enters house/yard

Familiar child enters house/yard

Response to toddlers/babies

In the car at toll booth/petrol stations

Unfamiliar adult approaches when dog on leash

Unfamiliar child approaches when dog on leash

Dog in house, sees people outside

Your dog’s response to off leash dogs when walking your dog on leash

Your dog’s response to on leash dogs when walking your dog on leash

Your dog’s response to off leash dogs when your dog off leash

Your dog’s response to on leash dogs when your dog off leash