Dog Behavior Helpline Questionnaire
Please be specific and provide as much detail as possible.
Contact Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Primary Phone
*
-
Area Code
Phone Number
Type
*
Please Select
Home
Cell
Work
Secondary Phone
-
Area Code
Phone Number
Type
Please Select
Home
Cell
Work
E-mail
*
How did you hear about the Behavior Helpline?
*
Other people in your household (include ages of children if applicable)
*
Pet Information
Name
*
Breeds (or best guess)
*
Sex
*
Please Select
Female/intact
Female/spayed
Male/intact
Male/neutered
Age
*
How long have you had your dog?
*
Where did you get your dog?
*
Veterinarian
*
Medical issues including allergies
*
Brand of food and amount (in cups)
*
Feeding schedule (check all that apply)
*
free feeds (food is available all/most of the time)
scheduled meals
eats immediately/finishes all
picky eater/grazes
Time(s) fed
Favorite treats/snacks
*
Prior training (i.e. tools used, classes taken, names of trainers, etc.)
*
Exercise routine (i.e. activity, distance/duration, frequecy, locations, etc.)
*
Other pets in your household (species, breed, age and sex/spayed or neutered )
*
Behavior Concern
Description of behavior concern. Please be as detailed as possible. Include facts about your pet's behavior, the environment in which it occurs, and frequency.
*
When did this behavior start?
*
Any environmental changes when the behavior started? (e.g. move, change in schedule, new family member, loss of family member, etc.)
*
What do you do when your dog exhibits this behavior? How does your dog respond to your actions?
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How much does your dog's behavior impact your day-to-day life?
*
1
2
3
4
5
very little
very much
1 is very little, 5 is very much
What changes (if any) have you made due to your dog's behavior?
*
Have you consulted your veterinarian about this behavior? Is yes, what was the result?
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Has your dog ever bitten or injured a person? If yes, provide details including circumstances leading to the incident, nature of injury and level of medical attention needed.
*
Has your dog ever injured another animal? If yes, provide details including circumstances leading up the incident, nature of injury and level of medical atttention needed.
*
Household information
Describe your dog's behavior with resident pets.
Describe your dog's behavior with non-resident dogs. Please include situations, locations, frequency and description of the other dogs.
Describe your dog's behavior and relationship(s) with human family members
*
How does your dog react when strangers come to the door? How does your dog interact with guests after they enter your home?
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How does your dog react to strangers outside of your home?
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Occupation and typical work/school schedule.
*
Where is your dog when home alone? For how long?
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Where does your dog sleep at night?
*
What are you hoping to achieve by contacting the Behavior Helpline?
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Are you considering re-homing your dog?
*
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