Pre-Consultation Behavioral History

Pre-Consultation Canine Behavioral History

About Dogs LLC, Camille Ward, M.S., M.S., Ph.D., CAAB, Certified Applied Animal Behaviorist
INSTRUCTIONS

Please read all questions carefully and answer to the best of your ability. Include all relevant information. Not all questions will apply to every dog. Detailed information is important for Dr. Ward to establish treatment. A well lled out history form will help to make the best use of the appointment time.

If multiple dogs are involved, please answer the questions as they apply for each dog or you can also fill out multiple behavioral forms, one for each dog.

This form should be completed by the actual pet owner or adult legal guardian and not by a third party.

Please return the completed Canine Behavioral History Form at least 3 business days prior to your dog’s appointment (the sooner the better for waitlisted appointments).

BEHAVIOR APPOINTMENTS

Initial appointments are approximately 2.0 hours in length. Follow-up appointments, if indicated, are normally 1.0 hour. However, longer follow-up appointments and remote appointments may be recommended in some cases.

Your dog should be hungry for the appointment. Please do not feed your dog a full meal within 3 hours of the appointment.

All persons who regularly interact with the dog should plan to attend the consult when possible.

Cancellations: Dr. Ward believes that every dog deserves the benefit of a thorough and comprehensive evaluation. As a result, Dr. Ward spends a significant amount of time in advance of your pet’s appointment performing a detailed review of your dog(s) completed Behavioral History Form (see below) so that she can spend more time during the assessment working through possible treatments and solutions. Additionally, Dr. Ward limits the number of dogs she sees each week so that she can provide the best care possible for each and every dog.

Appointments cancelled with at least a 14-day notice, no penalty. Appointments cancelled between 3 and 13 days, $200 fee; appointments cancelled within 72 hours of the scheduled time will be assessed the full appointment cost. Late cancellation fees will be charged to the credit card used to confirm the appointment.

Payment is due at the conclusion of the appointment for all in-person appointments and 72 hours in advance for new remote appointments. We accept cash, check, or credit card for payment.

Ann Arbor, MI

E: AboutDogsLLC@gmail.com

W: AboutDogsLLC.com

P: 734-358-1972

GENERAL INFORMATION
Full Names of all household members (include ages of children)
Today's date

MonthDayYear
How did you hear about us?*
Name of owner

First NameLast Name
Complete address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
E-mail*
E-mail
Dog's name
Dog's breed or breed mix
Age of dog
Date of birth

MonthDayYear
Weight
Sex

FemaleMale
Color
Spayed or neutered

YesNo
Age of neutering
Reason for neuter/spay
Any behavioral changes following spay/neuter
VETERINARY INFORMATION
Vet's name

First NameLast Name
Name of clinic
Business Phone number

Area CodePhone Number
E-mail
Fax number

Area CodePhone Number
Clinic address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of last physical

MonthDayYear
Describe any health problems
When was your dog last vaccinated for rabies? Note: Your dog MUST BE CURRENT on his/her rabies vaccine in order to be seen in person by Dr. Ward. *
If your dog is currently taking medication, please describe
BEHAVIORAL PROBLEMS
What is your dog's main behavioral problem?*
Additional problems
Please provide a detailed description (including dates) of:
The most recent incident*
The 2nd to last incident
The 3rd to last incident
Age of onset
Duration of each incident*
Frequency of occurrence*
Have there been any changes in the pattern, frequency, intensity and/or length of incidents from the time of onset to the present? Describe:
Are there any specific conditions, which seem to trigger the behavior? Is the behavior worse under certain conditions than others?
Can the dog be interrupted when engaged in the behavior

YesNo
Describe any methods used to stop the behavior and the dog’s response to these methods
Has your dog ever bitten?*

YesNo
If your dog has bitten, please describe the circumstances surrounding the bite and the degree of injury*
How long is the interval between the behavior stopping and the beginning of the next occurrence?
On a scale of 1-10, how would you rate your dog today in terms of his/her overall behavior over the last 2 weeks (1=worst ever, 10=best ever)?
DOG'S HISTORY
Where did you get your dog?
Age what age?
Do you know if the dog’s parents or siblings engaged in similar behaviors or in any other abnormal behaviors?
Other animals in the household, their species, breed age, sex and whether or not they are neutered. Which of these animals were living in the house when the dog was acquired?
Describe the interactions between the animals in the household
Describe the interactions between the dog and family members
How does your dog react to strangers?*
How does your dog behave in the veterinary office during an exam?
Does your dog live primarily inside or outside? Describe any restrictions to your dog’s movement inside the house?
DAILY ACTIVITIES
Please describe a typical 24 hour period in your dog’s life, start with where and when the dog wakes up in the morning
DIET
Type of food
Frequency of feeding and the amount fed
Other food/table scrapes, treats
EXERCISE
Amount of ON LEASH exercise DAILY, including location
Amount of OFF LEASH exercise DAILY, including location
Describe the type of fencing used to contain your dog
Type of collar and/or harness used when walking your dog
How much time do you spend actively playing with your dog? Describe how you play
How much time does your dog spend actively playing with other animals?
OBEDIENCE TRAINING
Have you ever attended obedience class with your dog?

YesNo
If your dog attended obedience class, where did she/he attend?
Types of methods used? Reward-based, treats, corrections? Please describe.
Have you ever used an electronic training collar (e.g., invisible fencing, barking collar, hand held remote trainer, etc.)? Please describe

Does your dog do any of the following?*

	Yes	No
Sit
Down
Stay
Come
"Watch" or "Look" (name attention)
Fetch
Tricks
Leave it
Walk on leash w/o pulling
Go to a mat and lie down on request

Describe any situation where your dog is less likely to listen to you.

Does your dog work well for

	Yes	No
Food
Ball, Frisbee, Retrieve Games
No Reward
Praise or Petting

Is your dog crate trained? *

YesNo
INTERACTIVE BEHAVIOR

Does your dog do any of the following?

	Yes	No
Does your dog demand to be petted?
Does your dog ever seem irritated or resent petting?
Does your dog bark excessively?
Does your dog cower or run away if people talk loudly or act boisterously?
Does your dog ever urinate or roll over on his/her back when greeting you?
Does your dog ever urinate or roll over on his/her back when greeting strangers?
Does your dog urinate or roll on his/her back when greeting strange dogs?
Is your dog comfortable in crowds?

How does your dog act when strangers come to the house?*
How does your dog act when he meets or passes strangers away from the house?
How Does your dog act when he meets unfamiliar dogs when:
1) Both are ON LEASH
2) Both are OFF LEASH
3) Your dog is ON LEASH and the other dog is OFF LEASH
Is your dog frightened excessively by anything? Describe:

Does your dog chase

	Yes	No
Running children
Bicyclist
Cars
Joggers
Cats or other animals

Does your dog urinate or defecate indoors?

YesNo
AGGRESSION SCREEN

Please complete this screen only if are meeting with Dr. Ward because of aggression. Please check the appropriate box if you dog ever exhibits any of the behaviors listed below at anytime when you or family members engage in the following:

AGGRESSION SCREEN

	Growl	Lift Lip	Snap	Bite	Never Tried	No Aggressive Response
Touch dog's food or add food while eating
Hit dog
Walk by dog in crate
Walk by/talk to dog on furniture
Remove dog from furniture either physically or verbally
Make dog respond to a command
Walk by dog eating
Pet dog
Suddenly reach for dog
Hug dog
Groom dog
Dry dog with towel
Trim nails or try to
Disturb dog while resting
Pull on leash

SEPARATION ANXIETY SCREEN

Please complete this screen only if your dog has ever exhibited problem behavior when left alone or appeared excessively anxious when you prepare to leave.

DOG'S HISTORY

	Yes	No	I don't know
Did you acquire your dog after 3 months of age?
Did you acquire your dog at 5 weeks of age or less?
Was your dog acquired from a shelter or a pound?
Has your dog had multiple owners during his/her life?
Was your dog acquired from a pet shop?
Was your puppy an orphan or hand raised?
Was your dog the single puppy in a litter?

DOG'S BEHAVIOR

	No	Mild	Moderate	Severe
Does your dog follow you around the house?
Does your dog become anxious at the sound of car keys?
Does your dog become anxious when you put on your coat or shoes?
Does your dog become aggressive when you leave?
Does your dog exhibit other problem behaviors as you prepare to leave?
Does your dog bark or whine excessively within 30 minutes of your departure?
After you leave does your dog's activity decrease?
After you leave does your dog appear depressed?
After you leave does your dog have a loss of appetite?
Only in your absence does your dog destroy property?
Only in your absence does your dog urinate or defecate in your home?
Does your dog regularly have diarrhea, vomit, or lick excessively in your absence?
Does your dog exhibit an excessive greeting on your return (jumping, hyperactivity, barking, more than 2-3 minutes)?

Any additional information that we should know about your dog?
Should be Empty:

Pre-Consultation Canine Behavioral History

GENERAL INFORMATION

VETERINARY INFORMATION

BEHAVIORAL PROBLEMS

DOG'S HISTORY

DAILY ACTIVITIES

DIET

EXERCISE

OBEDIENCE TRAINING

INTERACTIVE BEHAVIOR

AGGRESSION SCREEN

SEPARATION ANXIETY SCREEN