Behavior Questions For Dogs
Patient Info
Pet’s name
Breed
Date of Birth (approx age if N/A):
Sex
Male
Female
Spayed/Neutered
Yes
No
Owner Info
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Preferred Phone
Email
Additional Contacts
Name
Preferred Phone
Email
General Health
((If any have changed before or since Behaviors started describe)
Eating
Drinking
Current Diet/Frequency and Amount Fed
Defecation
Urination
Energy/Mobility
Vomiting?
Yes
No
Coughing/Sneezing?
Yes
No
Pain/Discomfort?
Yes
No
Current or Ongoing Health concerns
Current Medications (dosage/Frequency/form):
Behavioral Health
Describe the Behavior Issue(s)
Dates and Details of problematic incidents/occurrences
Where does the Behavior Occur?
Frequency of Behavior
When did Behavior first start?
Any Recent changes/ Has the Behavior been consistent?
Home Environment: Please list all people (including yourself) and other pets in the household
Name
Age
Species
Average daily hours in home
Quality of relationship with Pet
Poor
Neutral
Good
Great
Add Another?
Yes
No
Name
Age
Species
Average daily hours in home
Quality of relationship with Pet
Poor
Neutral
Good
Great
Add Another
Yes
No
Name
Age
Species
Average daily hours in home
Quality of relationship with Pet
Poor
Neutral
Good
Great
Frequent Visitors
Frequent Visitors
Occasional Visitors
Repair/Delivery Persons
What does your pet tend to resource guard (people, places things and/or food)
Who or what does your pet typically guard against (People either general or specific, or pets)
Training History
Has your dog ever attended a training class (if so please give details)
Has a Trainer ever worked with your dog (if so give details)
What Training methods have been used in the past? (i.e. clicker training, verbal corrections, etc)
What Behavior management products have been used (puzzle toys/feeders, easy lead harness, basket muzzle, increased physical or mental stimulation)
Has your pet worked with a veterinarian before? Who/what was diagnosed/what were treatments?
Has your pet been on medications for their behavior?
Section Break
What are your current Goals for your pet (comfort around strangers, sport/agility courses, companionship etc.)
What is the timeline you are working under (ex. Pet is staying with sitter they do not trust in 2 months)
Any comments/concerns would you like NWAH staff to know?
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