Canine Behavior History Questionnaire

SAN FRANCISCO PET BEHAVIOR

A VETERINARY CONSULTING SERVICE

Canine Behavior History Questionnaire

(Use TAB between fields)

Your name

PET INFORMATION

Dog's Name

Date of Birth

YYYY

Sex

Breed(s)

Color(s)

Weight

IMPORTANT Please provide most recent weight

If this dog is neutered/spayed, at what age?

Date of Last Rabies Vaccine

YYYY

Rabies Vaccine valid for

ACQUISITION INFORMATION

How old was this dog when acquired?

Why did you choose this dog?

Where did you obtain this dog?

Describe previous home(s) (if known)

Behavior of dog's parents/littermates (if known)

List any major household changes since acquiring this dog

e.g. moves, illness/death of pets/people, added new people/pets to the household, etc.

Have you had other dogs before?

BEHAVIOR PROBLEMS

What is the main behavior problem you wish to address at this appointment?

Describe when this problem first began

Describe the most recent incident of this problem

Describe any other significant incidents

Describe changes in your dog's body language or facial expressions before, during, or after the incidents

How frequently does this problem occur?

Is the frequency...?

What percent of time that your dog is in a potentially problematic situation does the problem behavior occur?

Describe what you've tried to correct the problem and what your dog's response has been

How serious do you find this problem?

Have you considered...

List other problem behaviors in order of importance to you

What would you like to see as an outcome for your upcoming appointment?

MEDICAL HISTORY

List any major illnesses/surgeries (include dates)

List ALL medications/treatments your dog is currently receiving

Include heart worm, flea prevention, dietary supplements, herbal/homeopathic treatments. Provide NAME OF MEDICATION, DOSAGE/FREQUENCY, DATE STARTED, ANY SIDE EFFECTS **HAVE ALL MEDICATION BOTTLES READY AND AVAILABLE FOR DR. KEELY COMMINS TO INSPECT IF THIS SECTION IS NOT COMPLETE, INCLUDING DOSAGES (mg)**

Previous BEHAVIOR-MODIFYING MEDICATIONS?

Please list all medications previously used for behavior problems. Provide NAME OF MEDICATION, DOSAGE/FREQUENCY, DATE STARTED, ANY SIDE EFFECTS, OVERALL EFFECTS

FEEDING

When and where is your dog fed?

Who feeds your dog?

What do you feed your dog?

What are your dog's eating habits?

SLEEPING

Where does your dog sleep?

If disturbed while sleeping, what is your dog's reaction?

EXERCISE

Does your dog get regular leash walks?

If NO, why?

If YES, who takes your dog for leash walks?

How often? For how long?

Location of walks

e.g. around neighborhood, in town, in park

What do you use to walk your dog?

How is your dog on leash?

Does your dog get off-leash exercise?

If YES, who takes your dog for off-leash exercise?

How often? For how long?

Location of walks

e.g. trails, dog parks, beaches

LIVING SPACES

Where does your dog spend the most time when people ARE HOME?

Where does your dog spend the most time when people ARE NOT HOME?

How long is your dog left alone on an average day? What times (e.g. 8:00am-5:00pm)?

What is your dog's reaction to being left alone?

Describe a typical 24 hour day in your dog's life

Start with when and where your dog wakes up in the morning, include feeding, exercise, and play times. If behavior problems occur at particular times of the day include that information.

TRAINING

Has your dog had any training?

What training techniques or tools have you used?

Select all that apply

Food rewards

Verbal praise

Play/toys

Choke collar

Prong collar

Remote collar (citronella, shock, vibration)

Bark collar (citronella, shock, vibration)

Other

Who in the household trained your dog?

What cues does your dog know?

Example: "sit", "down", "off"

Does your dog enjoy training?

How well does your dog obey cues WITHOUT distractions?

How well does your dog obey cues WITH distractions?

Is your dog crate trained?

BEHAVIOR SCREENS

best answer

House soiling (urine or feces)

Excessive barking/whining

Destructive chewing

Digging

Self licking/chewing

Pacing/repetitive behavior

Consuming non-food objects

Circling/chasing tail/freezing

Unfamiliar people at the door

Unfamiliar people in the home

Unfamiliar people, neutral territory, on leash

Unfamiliar people, neutral territory, off leash

Unfamiliar people, neutral territory, approaching/trying to pet

Joggers (adult)

Children

Babies

Bicycles

Cars/trucks driving by

Squirrels/cats/small animals

Unfamiliar dogs, on leash

Unfamiliar dogs, off leash

Other dogs in the home

Dog passing house/yard

Person passing house/yard

Veterinary Visits

Owners leaving

Owners returning

Car rides / driving in the car

Fireworks/thunder

Loud noises

Roughhousing

Reaction to walking by food dish while eating

Reaction to approaching food dish while eating

Reaction to walking by while eating treat

Reaction to taking away a non-edible toy

Reaction to taking away bone/rawhide

Reaction to taking away stolen non-food item (e.g. sock)

Reaction to taking away stolen food item (including tissues, dirty paper towels)

Reaction to reaching for an item at the same time as your dog

Reaction to reaching over head/petting top of head

Reaction to petting other parts of body

Brushing

Bathing

Picking up dog

Put on/take off collar/leash

Move while on furniture

Approaching your dog when sitting with its favorite person

Holding back when excited

Holding back when aggressive

Verbal reprimand

Physical reprimand

Leash correction

Staring at dog

Reaction to another dog when around regular food

Reaction to another dog when around treats

Reaction to another dog when around toys

Reaction to another dog when around favorite person

Reaction to another dog while playing

BITE SCREEN

Has your dog ever bitten a person?

If YES, describe the circumstances and the victim's age, gender

How bad was the worst bite your dog gave to a person?

Have any bites been reported to Animal Control or other authorities?

Have any victims threatened/taken legal action?

ADDITIONAL COMMENTS

Please include any additional information you'd like me to know

Thank you for taking the time to complete the Canine Behavior History Questionnaire! This information will allow our appointment to proceed much more smoothly. I look forward to helping improve the lives of both you and your dog.

Warmly,

Dr. Keely Commins