Canine Behavior History Questionnaire

(Use TAB between fields)

PET INFORMATION
Date of Birth
Date of Birth
Date of Last Rabies Vaccine
Date of Last Rabies Vaccine
ACQUISITION INFORMATION
e.g. moves, illness/death of pets/people, added new people/pets to the household, etc.
BEHAVIOR PROBLEMS
MEDICAL HISTORY
Include heart worm, flea prevention, dietary supplements, herbal/homeopathic treatments. Provide NAME OF MEDICATION, DOSAGE/FREQUENCY, DATE STARTED, ANY SIDE EFFECTS
FEEDING
SLEEPING
EXERCISE
e.g. around neighborhood, in town, in park
e.g. trails, dog parks, beaches
LIVING SPACES
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
BEHAVIOR SCREENS
best answer
BITE SCREEN
ADDITIONAL COMMENTS

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