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Canine Behavioral History
Please answer the following questions and bring this form with you to your
appointment (or if possible fax it ahead of time). Specific questions about the
problem behavior(s) will be asked during your visit.
General Information
| Date: |
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Clinic # |
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| Recorder: |
_________________ |
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| Client's name: |
_________________ |
Name of pet: |
_________________ |
| Address: |
_________________ |
Breed: |
_________________ |
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_________________ |
Date of Birth: |
_________________ |
| Home phone: |
_________________ |
Sex: ______ |
neutered/spayed: _______ |
| Work/Day phone: |
_________________ |
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Who is your regular veterinarian:
| Dr. |
_____________________________ |
| Clinic Name: |
_____________________________ |
| Address: |
_____________________________ |
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_____________________________ |
| Phone: |
_____________________________ |
What is the main behavior problem or complaint?
Additional problems (please list):
How frequently does the problem (or problems) occur (how many times daily,
weekly or monthly):
| a. Main Problem: |
Frequency: |
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| b. Other Problem: |
Frequency: |
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| c. Other Problem: |
Frequency: |
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Chronology Of The Behavior Problem
When did you first notice the main problem (age of dog)?
When did it first become a serious concern?
In what general circumstances does the dog misbehave?
Has this problem changed in frequency? (please describe)
Has this problem changed in intensity? (please describe)
Has this problem otherwise changed?
Describe several examples in detail:
1. Most recent incident: (Date: _________________)
2. Second to last incident: (Date: _________________)
3. Third to last incident: (Date: _________________)
Other significant incidents:
What have you done so far to try to correct the problem?
How do you discipline your dog for this and for other misbehavior?
Home Environment
Please list the people, including yourself, living in your household. Please
include ages of children:
| Name |
Hours Away From Home |
Please list all animals in the household including patient:
| Name |
Species |
Breed |
Sex |
Age Obtained |
Age Now |
In what sequence were the above animals obtained? (Please number animals in the
table above.)
What is your dog's relationship to the other animals
(e.g. friendly, hostile, fearful)? Please describe:
What type of area do you live in? (Circle one) City/Town
Suburbs Rural
What type of house do you live in? Please describe.
Have you moved since acquiring your dog? _____no _____yes How many times?
________
Has your household (people or animals) changed since acquiring your dog?
_____no _____yes, please describe:
Dog's Background
Why did you decide to get a dog?
Why did you choose this breed?
Where did you get this dog (circle one): SPCA
Breeder-newspaper ad/flyer Breeder - referral
Pet store Friend Stray
Other: _______________
Have you owned dogs before? _______yes ________no
If known: how many littermates? males ________ females ________
How many animals to choose from? ________________________
Why did you choose this dog over the others (please be specific):
Was a temperament test performed? ______yes ______no ______unsure
Result:
Describe your dog's behavior as a puppy:
Do you have any news about littermate behavior? (please describe)
Did you meet the parents? _____no _____yes, please describe their behavior:
Has this dog had other owners? ______no ______yes, how many? ____________
Why was the dog given up?________________
At what age was your pet neutered/spayed? ___________________________
Why was this done?
Were there any behavior changes after neutering?
If your pet is "intact" has he/she ever been bred? ________yes
________no
Are you planning to breed? ________yes ________no _________unsure
If you have an intact female, when was her last heat? Was it normal?
Diet and Feeding
What do you feed your dog? (Please be specific, e.g. brand name)
How much do you feed? (please be specific) Meal Times ____________________
Who feeds the dog?
Location ______________________
What is your dog's favorite treat?
Daily Schedule - Typical 24 hr day
Please describe a typical 24-hour day in your dog's life:
How does the dog behave with familiar visitors?
How does the dog behave with unfamiliar visitors (children or adults)?
How do you exercise your dog?
Is the dog free in a fenced yard?
Is the dog tied outside?
Does the dog run free?
How do you play with your dog?
What toys does the dog have?
Is your dog housetrained? _____no _____yes How was the dog
housetrained?
Does your dog ever eliminate in the house? _____no _____yes urinate
_____ defecate _____
Where does your dog sleep at night (please be specific):
__________________________
Where is your dog when alone in the house?
Where is your dog when you have guests?
How does your dog behave while you are leaving the house?
How does your dog behave when you return?
Obedience Training
What basic obedience training has your dog had? (Circle one)
None Trained at home
Started obedience classes but didn't finish
Graduated obedience class once Graduated
obedience class two or more
levels
Private trainer Other
___________________
How old was the dog when obedience training started?
Who in the family is the primary trainer?
Does your dog have any awards or titles? (Please describe)
Has your dog had any hunting, herding, protection, attack or Schutzhund
training?
What per cent of the time does your dog obey the following commands, for each
member of the family:
| Family Member |
Sit |
Down |
Stay |
Come |
Heel (Don't Pull) |
Does your dog know any tricks? Please describe:
Have you exhibited your dog in breed shows?
_____yes _____no _____no, but I plan to
Does your dog jump up on you or others without permission? _____yes _____no
Does your dog paw at you or at others? _____yes _____no
Does your dog lick you? _____yes _____no
Does your dog mount people? _____yes _____no
If yes, whom does he or she mount?
Does your dog mount other animals or objects? _____yes _____no Please describe:
Does your dog ever bark at you? _____no _____yes When? Please describe:
Does your dog bark at other times? Please describe:
What is your dog's activity level in general (Circle one):
Low Average
High Excessive
Medical History
Is your dog on any medication now, for this or other problems?
Has your dog been on medication in the past?
Date of most recent rabies vaccination: ________________(1 year, 3 year)
Aggression Screen
Animal Behavior Clinic
Cornell University
| GR - growl |
Owner: ________________ |
| SL - snarl/bare teeth |
Pet: ________________ |
| SB - snap/bite |
Date: ________________ |
| NR - no reaction |
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| NA - not applicable |
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GR |
SL |
SB |
NR |
NA |
| 1. pet dog |
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| 2. hug dog |
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| 3. kiss dog |
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| 4. lift dog |
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| 5. call off furniture |
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| 6. push/pull off furniture |
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| 7. approach on furniture |
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| 8. disturb while resting/sleeping |
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| 9. approach while eating |
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| 10. touch while eating |
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| 11. take dog food away |
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| 12. take human food away |
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| 13. take water dish away |
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| 14. take rawhide |
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| 15. take biscuit/cookie |
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| 16. take real bone |
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| 17. take toy/object |
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| 18. approach when dog has any object/toy/bone |
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| 19. verbally punish |
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| 20. physically punish |
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| 21. visual threat |
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| 22. speak to dog (normal tone) |
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| 23. stare at dog |
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| 24. bend over dog |
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| 25. push on shoulders or back |
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GR |
SL |
SB |
NR |
NA |
| 26. approach dog near spouse |
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| 27. enter room |
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| 28. leave room |
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| 29. reach toward dog |
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| 30. leash restraint |
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| 31. collar restraint |
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| 32. scruff restraint |
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| 33. put leash on/take off |
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| 34. put collar on/take off |
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| 35. bathe dog |
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| 36. towel dog |
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| 37. groom/brush dog |
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| 38. dog at groomer's |
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| 39. trim nails |
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| 40. leash/collar correction |
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| 41. response to "sit" |
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| 42. response to "down" |
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| 43. dog at veterinary clinic |
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| 44. unfamiliar adult enters house or yard |
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| 45. unfamiliar child enters house or yard |
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| 46. familiar adult enters house or yard |
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| 47. familiar child enters house or yard |
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| 48. response to toddlers/babies |
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| 49. dog in car at tollbooths, gas stations |
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| 50. unfam. adult approaches owner, dog on leash |
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| 51. unfam. child approaches owner, dog on leash |
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| 52. dog in house, sees people outside |
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| 53. response to other dogs, while on leash |
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| 54. response to other dogs, while not on leash |
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Where are you on a scale of 1 to 5 as follows:
- I am here only out of curiosity - problem is not serious.
- I would like to change the problem, but it is not serious.
- The problem is serious and I would like to change it, but if it remains
unchanged that's all right.
- The problem is very serious and I would like to change it, but if it
remains unchanged I will keep my dog.
- The problem is very serious and I would like to change it; if it remains
unchanged I will have my dog euthanized or give him/her up.
FOR AGGRESSION (TOWARDS PEOPLE) (Skip this section if aggression is not the
problem):
Please answer yes or no to these characteristics of your dog's aggressive
behavior:
______attacks are sudden and surprising
______episodes appear unprovoked
______the dog is abruptly docile after an episode
______the dog appears "sorry" afterwards
______the dog appears disoriented afterwards
______episodes are associated with a "glazed" or "absent"
expression
______I can usually tell what will set off my dog
______the aggressive behavior is new and uncharacteristic
Has your dog bitten and broken skin? _____yes _____no
Number of bites that broke skin:____________________
Total number of bites (that did or did not break skin):__________________
Total number of episodes of aggression (growling, snapping,
biting):______________
Describe typical episode (eg. does dog growl, lunge or bite, and in what
circumstance?):
If the dog is in the above situation 10 times, in how many of those times is
aggression seen (eg. all=100%, just one=10%, etc.)?
What parts of the body has the dog bitten and how severe were the injuries?
Who is/are the target(s) of aggression?
Did your dog bite as a puppy? _____yes _____no
If yes, please describe, including age:
How old was your dog the first time he/she growled at a person?
What was the circumstance?
How old was your dog the first time he/she snapped or bit at a person?
What was the circumstance?
(End of questionnaire - thank you!)
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