Canine History Form

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Client Information

First Name

Last Name

Phone Number

Email Address

Address

Dog Information

Name of Pet

Breed

Date of Birth

Veterinarian Information

Who is your regular veterinarian?

Doctor

Clinic Name

Address

Phone

Fax

Behavioral Information

What is the main behavior problem or complaint?

Additional problems (please list)

How frequently does the problem (or problems) occur (how many times daily, weekly or monthly)?

a. Main Problem:

b. Other Problem:

c. Other Problem:

a. Frequency:

b. Frequency

c. Frequency

Chronology of the Behavior Problem

When did you first notice the main problem (age of dog)?

When did it first become a serious concern?

In what general circumstances does your dog misbehave?

Has this problem changed in frequency? Please describe.

Has this problem changed in intensity? Please describe.

Has this problem otherwise changed?

Describe several examples in detail:

Most recent incident and date:

Second to last incident and date:

Third to last incident and date:

Describe any other significant incidents:

What have you done so far to try to correct the problem?

How do you discipline your dog for this behavior and for any other misbehavior?

Home Environment

Please list the people (including you) living in your household and ages of children.

Name

Age

Hours Away From Home

Name

Age

Hours Away From Home

Name

Age

Hours Away From Home

Name

Age

Hours Away From Home

Please list all animals in the household including the patient, in the sequence in which they were obtained.

Pet Name 1

Species / Breed / Sex

Age Obtained

Age Now

Pet Name 2

Species / Breed / Sex

Age Obtained

Age Now

Pet Name 3

Species / Breed / Sex

Age Obtained

Age Now

Pet Name 4

Species / Breed / Sex

Age Obtained

Age Now

What is your dog's relationship to the other animals (e.g. friendly, hostile, or fearful)? Please describe.

Have you moved since acquiring your dog? If yes, how many times?

Has your household changed (i.e., addition or loss of people or animals) since acquiring your dog? If yes, please describe.

Dog's Background

Why did you decide to get a dog?

Why did you choose this breed?

If known, how many littermates did your dog have? How many male and how many female?

How many animals were there from which to choose?

Why did you choose this dog over the others? Please be specific.

Was a temperament test performed? If yes, please describe the result.

Describe your dog's behavior as a puppy.

Do you have any information about the behavior of any littermates? Please describe.

Did you meet the parents? If yes, please describe their behavior.

Has this dog had other owners? If yes, how many? Why was the dog given up?

At what age was your pet neutered or spayed? Why was this done? Were there any behavior changes after neutering?

If your pet is "intact" has he/she ever been bred?

Are you planning to breed him/her?

If you have an intact female, when was her last heat? Was it normal?

Diet and Feeding

What do you feed your dog? (Please be specific, e.g., brand name)

Has your dog's appetite recently increased, decreased, or remained the same?

How much and at what time(s) do you feed your dog? Please be specific.

Who feeds your dog?

Where is your dog fed? Where does your dog drink?

What is your dog's favorite treat?

Daily Schedule - Typical 24 hour day

Please describe a typical 24-hour day in your dog's life:

How does your dog behave with familiar visitors?

How does your dog behave with unfamiliar visitors (children or adults)?

How do you exercise your dog?

Is your dog free in a fenced yard?

Is your dog tied outside?

Does your dog run free?

How do you play with your dog?

What toys does your dog have?

Is your dog housetrained? If yes, how was your dog housetrained?

Does your dog ever eliminate in the house? If yes, does your dog urinate, defecate or both?

Where does your dog sleep at night? Please be specific.

Has your dog’s sleeping habits changed? Please explain.

Where is your dog when alone in the house?

Where is your dog when you have guests?

How does your dog behave while you are getting ready to leave the house?

How does your dog behave when you return?

Obedience Training

If other, please describe:

How old was your dog when obedience training started?

Who in the family is the primary trainer?

Does your dog have any awards or titles? If yes, please describe.

Has your dog had any hunting, herding, protection, attack or Schutzhund training?

What percentage of the time does your dog obey the following commands for each member of the family?

Family Member 1

Sit

Down

Stay

Come

Heel

Family Member 2

Sit

Down

Stay

Come

Heel

Family Member 3

Sit

Down

Stay

Come

Heel

Family Member 4

Sit

Down

Stay

Come

Heel

Does your dog know any tricks? If yes, please describe.

Does your dog mount people? If yes, whom does he or she mount?

Does your dog mount other animals or objects?

Does your dog ever bark at you? If yes, when does your dog bark at you? Please describe.

Does your dog bark at other times? If yes, please describe.

What is your dog's activity level in general?

Low

Average

High

Excessive

Medical History

Date of most recent rabies vaccination? 1 year? 3 year?

Please list any medications (including supplements) that your dog is currently taking.

Has your dog ever been on any medication? If so, please explain.

Has your dog ever had any serious medical issues? Please explain.

Aggression Screen

Please indicate your dog’s reaction to each of the listed scenarios below using one of the following options.

GR = Growl

SL = Snarl/bare teeth

SB = Snap/Bite

NR = No Reaction

NA = Not Applicable

GR = Growl

SL = Snarl/bare teeth

SB = Snap/Bite

NR = No Reaction

NA = Not Applicable

GR = Growl

SL = Snarl/bare teeth

SB = Snap/Bite

NR = No Reaction

NA = Not Applicable

Where are you on a scale of 1 to 5 as follows?

Please choose the answer that best describes your situation:

1. I am here only out of curiosity—the problem is not serious.

2. I would like to change the problem, but it is not serious.

3. The problem is serious and I would like to change it, but if it remains unchanged that's all right.

4. The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog.

5. The problem is very serious and I would like to change it; if it remains unchanged I will have my dog euthanized or give him/her up.

For Aggression towards People

(Skip this section if aggression towards people is not the problem)

Please answer Yes or No to these characteristics of your dog's aggressive behavior:

Attacks are sudden and surprising

Yes

Episodes appear unprovoked

Yes

The dog is abruptly docile after an episode

Yes

The dog appears "sorry" afterwards

Yes

The dog appears disoriented afterwards

Yes

Episodes are associated with a "glazed" or "absent" expression

Yes

I can usually tell what will set off my dog

Yes

The aggressive behavior is new and uncharacteristic

Yes

Has your dog ever bitten and broken skin? If yes, total number of bites, (that did or did not break skin)

Total number of episodes of aggression (growling, snapping, or biting):

Describe a typical episode (e.g. does dog growl, lunge or bite, and in what circumstance?).

If your dog is in the above situation 10 times, in how many of those would he or she be aggressive (e.g., all 10 times = 100%, just one time = 10%, etc.)?

What parts of the body has your dog bitten? How severe were the injuries?

Who is/are the target(s) of aggression?

Did your dog bite as a puppy? If yes, please describe, including the puppy’s age.

How old was your dog the first time he/she growled at a person? What was the circumstance?

How old was your dog the first time he/she snapped or bit at a person? What was the circumstance?

Please add any other comments here:

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