Canine Behavior Questionnaire

Pet Parent Information

First and last name:(Required)

Address:(Required)

Primary phone number:(Required)

Email:(Required)

List all veterinary clinics your pet has visited in the past 5 years:

Who referred you to the behavior service?

Please list the names of anyone we have permission to speak with regarding your pet, including any family members who will not be present at the initial consultation. We may only discuss your pet with their primary care veterinarian, others require written authorization.

Pet Information

Pet name:

Breed:

Color:

Date of birth/Age:

Sex:

Spayed/Neutered:

Yes

Age of spay/neuter:

Where and when did you get your dog?

Has your dog had other (human) parents prior to living with you?

Yes

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

What are your goals for this appointment?

List any existing health issues your pet has, including allergies or sensitivities:

What do you feed your pet?

What do you love the most about your dog?

Recent research has shown connections between gut health and brain health. Please mark how often your dog has any of the following signs:

Vomiting

Diarrhea

Constipation

Decreased appetite

Excessive licking

Lip licking

Environmental Information

How many adults are in the household?

Are there any children, elderly members, or immunocompromised individuals in the household or who visit regularly?

Yes

Check all that apply to your pet’s environment:

Leash walked

Fenced yard

Tie out

Electric fence

Dog park

How many play sessions does your dog get per day?

List any other pets in the household and their relationship with the patient:

Presenting Concerns

List the first concern for which you are seeking help:

Age problem 1 started?

Unknown

Less than 4 months old

4 to 12 months old

1 to 3 years old

3 to 7 years old

7 years old or later

Frequency of problem 1?

Always

Sometimes

Rarely

Never

Has problem 1 gotten:

Better

Worse

Unchanged

Describe the most recent 2 incidents of this problem:

List the second concern for which you are seeking help:

Age problem 2 started?

Unknown

Less than 4 months old

4 to 12 months old

1 to 3 years old

3 to 7 years old

7 years old or later

Frequency of problem 2?

Always

Sometimes

Rarely

Never

Has problem 2 gotten:

Better

Worse

Unchanged

Describe the most recent 2 incidents of this problem:

List the third concern for which you are seeking help:

Age problem 3 started?

Unknown

Less than 4 months old

4 to 12 months old

1 to 3 years old

3 to 7 years old

7 years old or later

Frequency of problem 3?

Always

Sometimes

Rarely

Never

Has problem 3 gotten:

Better

Worse

Unchanged

Describe the most recent 2 incidents of this problem:

Previous Treatments

Check all previous treatments that have been tried:

Other treatment:

Have you and your dog ever worked with a dog training professional?

Yes

List any dog training professionals you have worked with, including puppy classes. List any behaviors taught and what your dog knows well.

Do you plan to continue working with the dog training professionals listed above?

Yes

Sleep Behaviors

Does your pet sleep through the night?

Yes

Have there been any changes in your pet’s sleeping patterns in the past 3 months?

Yes

Does your pet take naps during the day?

Yes

Aggressive Behaviors

Aggression describes a behavior, but it is not a personality trait. Aggressive behaviors include growling, lunging, biting, and some barking. If your dog has exhibited these behaviors in some situations, please answer the following section. If not, continue to the next section. These answers help your pet’s doctor appropriately diagnose and determine the best treatment plan for your dog.

Has your pet ever bitten at a person (this includes an air snap)?

Yes

Number of bites to a person:

Number of bites that broke skin:

Has your pet ever bitten at another dog (this includes an air snap)?

Yes

Number of bites to a dog:

Number of bites that broke skin:

Has a bite ever been reported to public health authorities?

Yes

Has there been any legal action regarding your dog’s behavior?

Yes

When is your dog aggressive?

What other time is your dog aggressive?

Who is your dog aggressive toward:

Check all that apply to your dog’s body language when they are aggressive:

Describe other body language when aggressive:

Car Behaviors

If your dog exhibits distress while riding in the car, please fill out the following section. If not, move on to Separation Behaviors.

Check all that apply to your dog’s behavior when riding in the car:

What other behavior does your dog exhibit when riding in the car?

Separation Behaviors

If your pet exhibits distress when separated from you or left alone, please fill out the following section. If not, move on to Storms/Sound Behaviors.

Where is your dog when you are not home?

Behavior while you are gone or cannot be reached (check all that apply):

Other behavior while you are gone or cannot be reached:

Behavior when you get ready to leave (check all that apply):

Aggressive toward you

Avoids going inside

Avoids being confined

Attempts to block you leaving

Calm

Hides

Looks sad

Follows you around

Other

Other behavior when you get ready to leave:

Does your dog exhibit this/these behavior(s) every time they are alone?

Yes

Does your dog exhibit this/these behavior(s) when a certain person departs, but not others?

Yes

Behavior when you return home or dog can reach you (check all that apply):

Calm, relaxed, or sleeping

Bark/whine/jump for <1 min

Bark/whine/jump for 1-2 mins

Bark/whine/jump for <5 mins

Bark/whine/jump for <10 mins

Bark/whine/jump for <15 mins

Bark/whine/jump for >15 mins

Other

Other behavior when you return home or dog can reach you:

Describe anything else you would like to share about your pet’s behavior when you leave:

Storms/Sound Behaviors

If your pet exhibits fear or stress related to storms or noises, please fill out the following section. If not, move on to Veterinary Visits.

What sounds cause your dog to exhibit fear or stress (check all that apply):

Other sounds that cause your dog to exhibit fear or stress?

What is your pet’s body language in response to a scary sound (check all that apply):

Other body language in response to a scary sound?

How long does it take your dog to calm down after sound/storm ends?

Veterinary Visit Behavior

Check all that apply to your dog in the veterinary office and during examination:

Check any other behaviors listed that your dog exhibits:

Circling

Snapping at air

Chase tail

Stare at lights/shadows

Have euthanasia or rehoming been recommended or considered prior to your visit with us?

Yes

Medical Records

Please have your veterinarian and any specialists your pet has seen send us your pet’s medical records, including any lab work. Documents can be uploaded below or sent by email to petshrink@pazvet.com or by fax to 512-481-7071.

The Day Of:

Please schedule a consult for all pets that are involved in the problem if you can do so safely. If multiple pets are involved and only one pet can come to the appointment, then the doctor may recommend a consult for your other pet(s) to adequately treat the problem. Please bring your pet's favorite toys and treats with you to the appointment so that we can use those items during your pet's appointment, if appropriate.

Photos and Videos

Videos of problem behaviors may be helpful. Do not under any circumstance invite or trigger aggressive behavior for the purpose of a video. Please limit videos to 2 minutes or less so they can be quickly added to your pet’s medical record.

File Uploads

Drop files here or

Max. file size: 50 MB.

Please be patient and allow all files to upload prior to continuing.

If you provide a video or pictures of your pet(s), would you give us permission to use them for teaching purposes in textbooks, publications such as journals, and during teaching presentations?

Yes

Each pet is an individual, so results of behavioral therapy cannot be guaranteed. While improvement can be seen quickly, many emotional disorders are chronic in nature and require continued therapy. Response to therapy is dependent on the individual’s response and the implementation of the recommendations made by your pet’s doctor. The behavior service is unable to guarantee that a treatment plan will be able to completely remove a patient’s aggression or potential danger to people or other animals. Pets should always be managed in accordance with local ordinances and leash laws.

By signing below, I acknowledge that:

I am the legal owner of the pet seeking behavioral medicine treatment from the behavior service at PAZ Veterinary.

Follow up appointments for behavior therapies range from every 4 to 6 weeks to every few months depending on the case.

Fees are to be paid at time of service and I accept responsibility for all charges that I approve related to the treatment of my pet.

I am seeking treatment by the behavior service with full knowledge of the above and of the liability associated with ownership of a pet that has exhibited aggression in the past.

Signature