Today's Date: *

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Email *

Dog's Name *

Breed

Color

Weight

Sex

Spayed / Neutered?

Yes
No

Age of Dog Now

Age of Neutering

Reason for Neutering

Any behavioral changes following neutering?

Name of Veterinarian and Veterinary Hospital

Date of last physical examination?

Any medical issues?

Please list all current medications & supplements (please include the dose)

Please list any previous behavior medications that have been tried (please include the dose and dates medication(s) were started and stopped)

Presenting Complaint

Please describe your dog's problem(s)

At what age did the problem start, if known?

How long does each incident last, if known?

How often does it occur?

Have there been any changes in the pattern, frequency, intensity and/or length of incidents from the time of onset to the present?

Are there any specific conditions which seem to trigger the behavior?

Can your dog be verbally or physically interrupted when engaged in the problem behavior?

Please give a detailed description of the last 2 times this problem occurred:

Dog's History

Where did you get your dog?

At what age was your dog acquired?

Do you have information about your dog’s history before you acquired him? If so, please explain.

Do you know if your dog's parents or siblings engaged in similar behaviors or any other abnormal behaviors?

List people living in the house with the dog. Please include children's ages:

List all other animals in the household, their species, breed, age, sex and whether or not they are neutered. Please indicate which of these animals were living in the house when this dog was acquired:

Describe interactions between animals in the household:

Describe interactions between your dog and family members:

Behavior of your dog in the veterinary office and during examination:

Diet

Type of food given

Frequency of feeding

Other food/treats/table scraps

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:

Exercise

On leash, include location:

Off leash, include location:

Time spent playing actively with owner. Describe activities which take place:

Do you have a fenced-in yard or the Invisible Fence?

Time spent actively playing with other animals:

Training

What type of collar or harness does your dog use?

When training, what is your dog’s preferred reward?

Have you attended training classes with your dog? If so please describe the class(es):

Have you previously enlisted the help of a trainer, behaviorist or veterinarian for help with this behavior problem?

What recommendations were you given?

Was there any improvement?

Does your dog do the following willingly (please check all the apply):

Situations in which your dog is less likely to obey you:

Does your dog demand to be petted?

Does your dog ever seem irritated by or resent petting?

Does your dog bark excessively? In what context?

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 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 strange dogs? 1. When both are on the leash:

How does your dog act when he meets strange dogs? 2. When both are off leash:

How does your dog act when he meets strange dogs? 3. When he is leashed, and another dog is free:

Is your dog frightened excessively by any noise? Please explain.

Is your dog frightened excessively by anything else in the environment? Please explain.

Does your dog chase any of the following: (please check all that apply)

Does your dog urinate/defecate in the house?

Behaviors your dog exhibits when members of the household do the following

Touch dog's food or add food while eating

Walk past dog while eating

Take away real bone, rawhide, or delicious food

Walk by dog when s/he has a real bone/rawhide

Touch delicious food when dog is eating

Take away a stolen object

Physically wake dog up or disturb resting dog

Restrain dog when it wants to go someplace

Lift dog

Pet dog

Medicate dog

Handle dog's face/mouth

Handle dog's feet

Trim the dog's toenails

Groom dog

Bathe or towel off

Take off or put on collar

Pull dog back by the collar or scruff

Reach for or grab dog by the collar

Hold dog by the muzzle

Stare at the dog

Reprimand dog in loud voice

Visually threaten dog: newspaper or hand

Hit the dog

Walk by dog in crate

Walk by/talk to dog on furniture

Remove dog from furniture: physically or verbally

Make dog respond to command

Does your dog get a glazed look in his/her eyes?

Does your dog have a Jeckyl and Hyde personality?

Do you consider your dog hyperactive?

Behaviors your dog exhibits

When approached by unfamiliar ADULT while on leash

When approached by an unfamiliar CHILD while on leash

When an unfamiliar person tries to touch or pet the dog

When unfamiliar people enter your home

When examined or handled by a veterinarian

Walking through a crowd of people

When approached directly by an unfamiliar dog while on a leash

When unfamiliar dogs are visiting your home

When being barked, growled, or lunged at by an unfamiliar dog

When approached directly by an unfamiliar dog of the same or larger size

When approached directly by an unfamiliar dog of a smaller size

When your dog sees another dog f rom a distance

Did you acquire your dog after 3 months of age?

Yes
No
I don't know

Did you acquire your dog at 5 weeks of age or less?

Yes
No
I don't know

Was your dog acquired from a shelter or a pound?

Yes
No
I don't know

Has your dog had multiple owners during his/her life?

Yes
No
I don't know

Was your dog acquired from a pet shop?

Yes
No
I don't know

Was your puppy an orphan or hand raised?

Yes
No
I don't know

Was your dog the single puppy in a litter?

Yes
No
I don't know

Does your dog follow you around the house?

No
Mild
Moderate
Severe

Does your dog become anxious at the sound of car keys?

No
Mild
Moderate
Severe

Does your dog become anxious when you put on your coat or shoes?

No
Mild
Moderate
Severe

Does your dog become aggressive when you leave?

No
Mild
Moderate
Severe

Does your dog exhibit other problem behaviors as you prepare to leave?

No
Mild
Moderate
Severe

Does your dog bark or whine excessively within 30 minutes of your departure?

No
Mild
Moderate
Severe

After you leave does your dog's activity decrease?

No
Mild
Moderate
Severe

After you leave does your dog appear depressed?

No
Mild
Moderate
Severe

After you leave does your dog have a loss of appetite?

No
Mild
Moderate
Severe

Only in your absence does your dog destroy property?

No
Mild
Moderate
Severe

Only in your absence does your dog urinate or defecate in your home?

No
Mild
Moderate
Severe

Does your dog regularly have diarrhea, vomit, or lick excessively in your absence?

No
Mild
Moderate
Severe

Does your dog exhibit an excessive greeting on your return (jumping, hyperactivity, barking, more than 2-3 minutes)?

No
Mild
Moderate
Severe

Please have your veterinarian send us your pet's medical record including lab work. Documents can be sent by email to michelle@islandpetvethospital.com or by fax to 252-631-0383.

Check in for stressed patients: If your pet becomes excessively stressed at the vet's office and you would like to check in from the car, please call 252-702-8299 as soon as you arrive for your pet's consultation. One of our front desk staff will take your information and let us know you have arrived and where to find you. We will then escort you to our separate entrance so you can avoid the waiting room.

If you provide a video or pictures of your pet(s), would you give us permission to use them for teaching purposes?

Yes
No

Canine Questionnaire