Pre-Consultation Behavioral History

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 filled 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.

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 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 6 hours of the appointment.
All persons who regularly interact with the dog should plan to attend the consult.
Please provide us with the professional courtesy of 72 hours notice if you need to cancel/reschedule appointments. Only a limited number of appointments are available each week, and a large block of time reserved for each one.
A credit card is used to hold the appointment. A $50.00 charge will be incurred for cancelled appointments.

Payment is due at the conclusion of the appointment. 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

Today's date

Month Day Year Date Picker Icon

How did you hear about us?

Name of owner

First Name Last Name

Full Names of all household members (include ages of children)

Complete address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

E-mail

Email is Dr. Ward's preferred method of contact. May we contact you by email?

Yes No

Dog's name

Dog's breed or breed mix

Age of dog

Date of birth

Month Day Year Date Picker Icon

Weight

Sex

Female Male

Color

Spayed or neutered

Yes No

Age of neutering

Reason for neuter/spay

Any behavioral changes following spay/neuter

VETERINARY INFORMATION

Vet's name

First Name Last Name

Name of clinic

Home Phone number

Area Code Phone Number

Cell Phone number

Area Code Phone Number

Fax number

Area Code Phone Number

Clinic address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date of last physical

Month Day Year Date Picker Icon

Describe any health problems

When was your dog last vaccinated for rabies? *

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

Yes No

Describe any methods used to stop the behavior and the dog’s response to these methods

Has your dog ever bitten? *

Yes No

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?

Yes No

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? *

Yes No

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?

Yes No

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:

	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 toweel
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?

Pre-Consultation Canine Behavioral History

INSTRUCTIONS

BEHAVIOR APPOINTMENTS

GENERAL INFORMATION

VETERINARY INFORMATION

BEHAVIORAL PROBLEMS

DOG'S HISTORY

DAILY ACTIVITIES

DIET

EXERCISE

OBEDIENCE TRAINING

INTERACTIVE BEHAVIOR

AGGRESSION SCREEN

SEPARATION ANXIETY SCREEN