Canine Behavior History Form

Patient (Pet's) Name:

List all other family members (names):

Adult Name:
Adult Name:
Adult Name:
Child Name & Age:
Child Name & Age:
Child Name & Age:
Child Name & Age:

Who is the primary caretaker of this pet?

Please tell us about the pets living in your household.

Patient Name and Breed:
Pet 2 Name and Breed:
Pet 3 Name and Breed:
Pet 4 Name and Breed:
Pet 5 Name and Breed:

Please tell us more about the pets in your household. For each, please tell us their sex, if they are spayed or neutered, their age, and in what order they were adopted.

Patient Sex, Spay/Neuter, Age, Adoption Order:
Pet 2 Sex, Spay/Neuter, Age, Adoption Order:
Pet 3 Sex, Spay/Neuter, Age, Adoption Order:
Pet 4 Sex, Spay/Neuter, Age, Adoption Order:
Pet 5 Sex, Spay/Neuter, Age, Adoption Order:

If the patient is spayed/neutered, at what age were they spayed/neutered?

Months
Years
Unknown

Are any pets currently ill?

yes

no

If yes, please explain:

Veterinarian information:

Veterinarian Name:
Phone Number:

Does the patient have any medical problems?

yes

no

If yes, please describe:

If your pet is on medication, please list them:

Patient Weight:

How long have you had your pet, and how old were they when you acquired them?

Where did you acquire your pet?

Pet Store

Shelter

Breeder

Stray

Rescue

Other

Reason for selecting this pet:

family pet

watch dog

adult pet

outdoors only

child's pet

service

breeding

showing

hunting

Other

Answer the following only if your dog was obtained as a puppy (< 6 mos old):

How was the dog raised in the previous home?

Crate Trained

Barn/farm

Outdoor kennel/garage

Loose outdoors

Puppy Mill

Unknown

Answer the following only if your dog was obtained as a puppy (< 6 mos old):

How did you select this puppy from the litter?

Breeder Selected

Most outgoing

Most timid

Looks/Color

Biggest

N/A

Smallest

Other

Average number of hours this pet is left alone on a daily basis:

Where is this pet kept when along?

Crated

Confined to a room

Garage

Basement

Fenced yard

Tethered outdoors

Loose in the house

Outdoor kennel

Where does your pet sleep at night?

Crated

Confined to a room

Garage

Outdoor Kennel

Basement

Fenced Yard

Tethered outdoors

Bedroom Floor

On person's bed

What is your living situation?

House

Apartment

Other

Owned

Rental

Do you have a fenced yard?

yes

no

If you have a fenced yard, is it

Wood/Privacy

Chain Link

Invisible

Other

What forms of exercise does your dog participate in? How Often?

	Daily	Once a week	Twice a week	Three times a week or more	Seldom to Never
Jogs with person
Outdoors, unsupervised runs free
Access to a fenced backyard, unsupervised
Swimming
Outdoors, supervised, unleashed
Leash walks

If you take your dog for a walk, how long is each walk, in minutes?

Your pet's exercise schedule is

consistent

varies

Your dog is walked using

Flat Collar

Off-Leash

Retractable leash

Harness

Gentle Leader/Headcollar

Easy Walk Harness

Choke Chain

Pinch/Prong

Shock Collar

Other

Does your dog pull on the leash?

yes

no

Would you like advise to help prevent your dog from pulling on the leash?

yes

no

Children of various ages may be present and have access to your dog during a playgroup or training session. Is your dog comfortable around, able to be petted/touched and friendly with children of all ages?

yes

no

unknown

Is there anything we should know regarding your dog interacting with children?

My dog has never played off leash before with dogs in a group setting.

yes

no

My dog has played off leash with other dogs (check all that apply)

< 10 lbs.

< 25 lbs.

< 25 lbs. only

> 25 lbs. only

> 50 lbs.

When interacting with other dogs I feel my dog:

is having fun

does not want to play

always gets picked on

gets too rough/I sometimes separate them

is scared, runs and hides

tries to nip/snap at other dogs

barks/lunges on leash

has no opportunity to play with other dogs

I do not know

is not interested

I'm not sure how to interpret my dog's behavior when playing with other dogs.

Has your dog ever attended training classes?

yes

no

Where has your dog attended training classes?

Puppy Pre-school (< 4 months of age)

4-H Training

Obedience Class

Other

When and where did your dog attend training classes?

When
Where

How old was your dog at the start of the class?

Months:
Years:

What type of training equipment was used?

Flat Collar

Off-Leash

Retractable Leash

Harness

Gentle Leader

Choke Chain

Pinch/Prong

Shock Collar

Please tell us about your dog's level of training:

	Perfect	Ok	Needs Work	N/A
Sit
Lie Down
Come
Wait
Drop It
Leave It
Heel
Other

Please select the discipline techniques your dog is familiar with

none ever

startling

scruff shake

verbal reprimand

time out

physical reprimand

ignore

re-direct

alpha roll over

water pistol

leash jerk

grab collar

distraction

shock collar

citronella collar

Please select any of the following that are of concern with this pet

Jumps up on people

Destructive chewing

Inappropriate elimination

Pulls on leash

Growls

Bites

Aggressive to Humans

Aggressive to Dogs

Aggressive to Cats

Too Attached to Me

Fear Biting

Excessive energy

Does not listen

Does not come when called

Protects food or toys from me

Chases

Other

Please tell us about your dog's diet

Dry Brand:
Wet Brand:
Treat Brand:
Other Brand:

Please tell us what percentage of each type of food contributes to your pet's whole diet.

Dry %:
Canned %:
Treats %:
Other %:

What is your pet's feeding schedule

Once/Daily

Twice Daily

Three Times Daily

Ad Lib

Does your dog eat table food? If so, please list the table food your dog consumes and how frequently.

Key:

Happy = experience is enjoyable, fully tolerates, asks for more.
Anxious = tolerates, but would prefer to avoid if possible, may shake, nervous, but does not attempt to growl, snap, bite, or run away.
Aggressive = persistent barking, may lunge forward, intense focus on object: owner unable to distract, may need to be muzzled for procedure, attempts to growl, snap or bite.
Hyper = more than merely excited, may be combined with anxiety, persistent or repates behaviors, difficult to distract.
Fearful = nervous, anxious, attempts to escape, body posture reflects dog is prepared to run away or may attempt to growl, snap or bite (Fight or Flight)
Neutral no response, dog does not care
Unknown do not know, has never been attempted or exposed.

	Happy	Anxious	Aggressive	Hyper	Fearful	Neutral	Unknown
Unfamiliar person at door
Being petted by person (on leash)
Babies (< 1 year)
Children 1- 6 years
Children 7-11 years
Children 12-18 years
Bicyclists
Rollerblades/Skateboarders
Car Rides
Joggers
Vehicles passing by (on leash)
Doorbell/Knocking
Vehicle/Loud Stereo/Pipes/Semi
Going into Crate/Carrier
Person Passing on Sidewalk (on leash)
Loud Noises
Thunderstorms
Owner reaching over/petting on head
Hugging
Touching ears
Nail trims
Wiping feet
Being lifted up
Grasping by collar
Putting on/taking off collar
Being stared at
Bruising
Bathing
Professional grooming
Being approached when on dog bed
Owner leaving
Owner returning
Being disturbed while asleep
Being stepped over when lying on floor
Verbal reprimand
Physical reprimand
Approaching bowl when eating
Remove rawhide/pig ear from mouth
Picking up food bowl while eating

Do you have a way to take digital photos and videos? you may be asked to submit photos and videos as this can be a vital source of information.

yes

no

For each problem, please be as specific and detailed as possible in your answers. For each incident answer the following questions:

What happens?
Where does it occur?
Who is present?
What triggers the event?
What does the dog look like (body language) just before the event and afterward?
How do you react to the event?
What do you do specifically?
Problem:

Canine Behavior History Form

Patient (Pet's) Name:

Household Information

List all other family members (names):

Who is the primary caretaker of this pet?

Pet Information

Please tell us about the pets living in your household.

Please tell us more about the pets in your household. For each, please tell us their sex, if they are spayed or neutered, their age, and in what order they were adopted.

If the patient is spayed/neutered, at what age were they spayed/neutered?

Are any pets currently ill?

If yes, please explain:

Veterinarian information:

Does the patient have any medical problems?

If yes, please describe:

If your pet is on medication, please list them:

Patient Information:

Patient Weight:

How long have you had your pet, and how old were they when you acquired them?

Where did you acquire your pet?

Reason for selecting this pet:

Answer the following only if your dog was obtained as a puppy (< 6 mos old): How was the dog raised in the previous home?

Answer the following only if your dog was obtained as a puppy (< 6 mos old): How did you select this puppy from the litter?

Daily Routine

Average number of hours this pet is left alone on a daily basis:

Where is this pet kept when along?

Where does your pet sleep at night?

What is your living situation?

Do you have a fenced yard?

If you have a fenced yard, is it

What forms of exercise does your dog participate in? How Often?

If you take your dog for a walk, how long is each walk, in minutes?

Your pet's exercise schedule is

Your dog is walked using

Does your dog pull on the leash?

Would you like advise to help prevent your dog from pulling on the leash?

Relationships/Interactions

Children of various ages may be present and have access to your dog during a playgroup or training session. Is your dog comfortable around, able to be petted/touched and friendly with children of all ages?

Is there anything we should know regarding your dog interacting with children?

My dog has never played off leash before with dogs in a group setting.

My dog has played off leash with other dogs (check all that apply)

When interacting with other dogs I feel my dog:

Has your dog ever attended training classes?

Where has your dog attended training classes?

When and where did your dog attend training classes?

How old was your dog at the start of the class?

What type of training equipment was used?

Please tell us about your dog's level of training:

Please select the discipline techniques your dog is familiar with

Please select any of the following that are of concern with this pet

Diet

Please tell us about your dog's diet

Please tell us what percentage of each type of food contributes to your pet's whole diet.

What is your pet's feeding schedule

Does your dog eat table food? If so, please list the table food your dog consumes and how frequently.

General Behavioral Profile

Problem History

Do you have a way to take digital photos and videos? you may be asked to submit photos and videos as this can be a vital source of information.

Most Recent Incident

2nd Most Recent Incident

3rd Most Recent Incident

Answer the following only if your dog was obtained as a puppy (< 6 mos old):

How was the dog raised in the previous home?

Answer the following only if your dog was obtained as a puppy (< 6 mos old):

How did you select this puppy from the litter?