Canine Behavior History Form



351028024765Carolina Veterinary Behavior ClinicDr. Jillian Orlando, DVM, DACVB409 Vick AvenueRaleigh, NC 27612 Phone: (919) 791-9058Fax: (919) 324-3822appointments@00Carolina Veterinary Behavior ClinicDr. Jillian Orlando, DVM, DACVB409 Vick AvenueRaleigh, NC 27612 Phone: (919) 791-9058Fax: (919) 324-3822appointments@CANINE BEHAVIORAL HISTORY FORMThis questionnaire is long but is crucial to helping understand your pet’s problem behaviors as well as screen for other potential behavioral problems. Please fill out this form in its entirety and return it to the CVBC by email or fax. CLIENT AND PATIENT INFORMATIONCLIENT INFORMATIONLast Name: FORMTEXT ????? First Name: FORMTEXT ????? Street Address: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Home Phone: FORMTEXT ????? Cell Phone: FORMTEXT ????? E-mail address: FORMTEXT ????? Spouse/Partner First Name: FORMTEXT ????? Last Name: FORMTEXT ?????PET INFORMATIONName: FORMTEXT ????? Breed: FORMTEXT ????? Color: FORMTEXT ????? Date of birth: FORMTEXT ????? Age: FORMTEXT ????? Weight: FORMTEXT ?????Sex: Male (intact) ?Male (neutered) ?Female (intact) ?Female (spayed) ? Age when obtained: FORMTEXT ????? Age neutered or spayed: FORMTEXT ?????Where did you obtain this dog? FORMTEXT ?????BREEDER ?PET STORE ?ANIMAL SHELTER ?RESCUE ? FRIEND ? OTHER FORMTEXT ?????VETERINARY INFORMATIONYour primary veterinarian’s name: FORMTEXT ?????Name of Clinic or Hospital: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Office Phone: FORMTEXT ?????Fax: FORMTEXT ?????How did you hear about the Carolina Veterinary Behavior Clinic? FORMTEXT ?????HOUSEHOLD INFORMATIONPERSONS LIVING IN THE HOUSEHOLDNameAgeSexHours Away from Home Interaction with pet FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ?????PETS LIVING IN THE HOUSEHOLDNameSpeciesBreedAgeSexWeightInteraction with patient pet FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????BEHAVIORAL PROBLEMSPlease list your pet’s top 3 behavioral problems that you would like to address: FORMTEXT ?????How would you describe the severity of this problem? MILD ? MODERATE ? SEVERE ?How often does this problem occur? FORMTEXT ?????Total number of times this has occurred? FORMTEXT ????? FORMTEXT ?????How would you describe the severity of this problem? MILD ? MODERATE ? SEVERE ?How often does this problem occur? FORMTEXT ?????Total number of times this has occurred? FORMTEXT ????? FORMTEXT ?????How would you describe the severity of this problem? MILD ? MODERATE ? SEVERE ?How often does this problem occur? FORMTEXT ?????Total number of times this has occurred? FORMTEXT ?????What are your goals for treatment? FORMTEXT ?????Have you considered euthanasia?YES ?NO ?Please comment: FORMTEXT ?????Describe the worst two incidents in as much detail as possible.Date: FORMTEXT ????? Incident: FORMTEXT ?????Date: FORMTEXT ????? Incident: FORMTEXT ?????PROBLEM BEHAVIOR HISTORYHow old was your pet when the problem(s) began? FORMTEXT ?????Were there changes in the home at that time? FORMTEXT ?????What do you think is the reason for your dog’s problem? FORMTEXT ?????List techniques you have used to address the problem(s). Put (+) next to techniques that seem to have helped.Put (-) next to techniques that made things worse.Put (0) next to techniques that had no effect.1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????List any medication, supplements, or other remedies your pet has received for its behavioral problem(s)? Put (+) next to ones that seem to have helped.Put (-) next to ones that made things worse.Put (0) next to ones that had no effect.1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????PUNISHMENTSIndicate any correction techniques you have used and indicate their effects on your dog’s behavior.TypeHave you Tried?Improved ProblemNo Effect Made WorseCommentsTime outYes ? No ???? FORMTEXT ?????Leash jerksYes ? No ???? FORMTEXT ?????Verbal scolding Yes ? No ???? FORMTEXT ?????NoisemakerYes ? No ???? FORMTEXT ?????Water bottleYes ? No ???? FORMTEXT ?????Spanking/smackingYes ? No ???? FORMTEXT ?????Forced alpha rollYes ? No ???? FORMTEXT ?????Other FORMTEXT ?????Yes ? No ???? FORMTEXT ?????SPECIFIC BEHAVIORAL HISTORY/SCREENINGHANDLINGCheck how your dog responds to the following tasks:TASKNO REACTIONAVOIDSRESISTSGROWLSSNAPSCOMMENTSTrimming nails????? FORMTEXT ?????Giving pill????? FORMTEXT ?????Cleaning ears????? FORMTEXT ?????Grooming????? FORMTEXT ?????Bathing????? FORMTEXT ?????Patting Head????? FORMTEXT ?????Grasping Collar????? FORMTEXT ?????Being Lifted????? FORMTEXT ?????Rolling Over????? FORMTEXT ?????AGGRESSIONIndicate your dog’s response to the following situations. Check all that apply.Taskn/aNo ResponseFreezes/StaresBarks GrowlsLifts LipSnaps/ BitesCommentsWhen dog is approached while eating??????? FORMTEXT ?????When approached while chewing a high value treat/toy??????? FORMTEXT ?????When taking away a stolen object or high value treat/toy??????? FORMTEXT ?????When dog is scolded??????? FORMTEXT ?????When dog is spanked??????? FORMTEXT ?????When dog is pushed off furniture (bed, couch)??????? FORMTEXT ?????When dog is approached while resting/sleeping??????? FORMTEXT ?????Ever, to family members??????? FORMTEXT ?????To strangers in the yard or at the door ??????? FORMTEXT ?????To strangers entering house ??????? FORMTEXT ?????Ever, to children or infants??????? FORMTEXT ?????While in car, to persons outside car??????? FORMTEXT ?????To painful stimuli (injection or removing tick)??????? FORMTEXT ?????To familiar dogs in your home??????? FORMTEXT ?????To unfamiliar dogs outside your home??????? FORMTEXT ?????Describe any situation in which your dog is muzzled for safety: FORMTEXT ?????Describe any situation in which you are, or any family member is, afraid of your dog: FORMTEXT ?????Has your dog been reported to animal control authorities or a public health department for biting? YES ? NO ?Is your pet currently in 10-day quarantine for biting? YES ? NO ?Has any legal action been taken against you/your dog? FORMTEXT ?????BITE HISTORYTYPE OF BITEHas Occurred To a DogTo a Human Total # of IncidentsCOMMENTSSnapped at, no contact??? FORMTEXT ????? FORMTEXT ?????Made contact, no mark??? FORMTEXT ????? FORMTEXT ?????Small red mark??? FORMTEXT ????? FORMTEXT ?????Bruised, no broken skin??? FORMTEXT ????? FORMTEXT ?????Broke skin, minor scrape??? FORMTEXT ????? FORMTEXT ?????Puncture??? FORMTEXT ????? FORMTEXT ?????Multiple punctures??? FORMTEXT ????? FORMTEXT ?????Laceration, torn flesh??? FORMTEXT ????? FORMTEXT ?????Severe mutilation, death??? FORMTEXT ????? FORMTEXT ?????Required ER treatment??? FORMTEXT ????? FORMTEXT ?????ATTACHMENT AND SEPARATION ANXIETYWhen you are home, does your dog follow you from room to room? FORMTEXT ?????Does your dog always insist on lying on or near you? FORMTEXT ?????Does your dog become anxious if left inside the house while you are in the yard? FORMTEXT ?????Does your dog become anxious if closed outside of the bathroom while you shower, etc.? FORMTEXT ?????How often is your dog left home alone (no people in the house)? FORMTEXT ?????For how many hours is your dog alone? FORMTEXT ?????What is your pet’s reaction to your routine departures (eg. Going to work or school daily)? FORMTEXT ?????What is your pet’s reaction to unexpected departures (eg. Going out to dinner, running an errand)? FORMTEXT ?????What is your pet’s reaction to your return home? FORMTEXT ?????If your dog shows anxiety when household members leave:Do they show anxiety when any member leaves even if others are still home? FORMTEXT ?????Do they only show anxiety when the last person leaves the house (being left alone)? FORMTEXT ?????Do they only show anxiety when a specific person leaves and ignores other people leaving? FORMTEXT ?????Have you ever used a crate or kennel for confinement? YES ? NO ?Do you still use a crate or kennel? YES ? NO ? If yes, does your dog enter their crate willingly? FORMTEXT ?????What is your dog’s behavior while crate (ex. tries to escape, sleeps, etc.)? FORMTEXT ????? Where in the home is your dog’s crate located? FORMTEXT ????? If your dog is not crated, do you keep him/her confined to certain areas of the house while alone (ex. in the bedroom or kitchen)? FORMTEXT ????? If so, where? FORMTEXT ?????If so, what barrier is used to keep him/her confined (ex. closed door, baby gate, etc.)? FORMTEXT ?????Please specify any special conditions you arrange for your dog when left home alone such as leaving him/her with a stuffed Kong, leaving the TV/radio on, scheduling a dog walker to come, etc.: FORMTEXT ?????FEAR AND ANXIETYHow does your dog react to thunderstorms? FORMTEXT ?????How does your dog react to light rain/mild storms? FORMTEXT ?????How does your dog react to fireworks? FORMTEXT ?????Does your dog react fearfully to other loud noises (gunshots, engine backfire, etc)? FORMTEXT ?????Please describe: FORMTEXT ?????Does your dog react fearfully to loud kitchen appliances or the vacuum cleaner? FORMTEXT ?????Does your dog react fearfully to riding in the car? FORMTEXT ?????Does your dog react fearfully to going places (vet’s, pet store, friend’s house)? FORMTEXT ?????Please use the following chart to list what anxious behaviors your dog shows during specific situations (including the ones mentioned above):Signs of anxietySituations in which it occursCowering FORMTEXT ?????Trembling FORMTEXT ?????Ears back FORMTEXT ?????Tail tucked FORMTEXT ?????Retreating/backing away FORMTEXT ?????Hiding (under bed, behind couch) FORMTEXT ?????Whining/crying in distress FORMTEXT ?????Excessive panting FORMTEXT ?????Drooling FORMTEXT ?????Pacing FORMTEXT ?????Please make any additional comments regarding fear or anxiety in your dog: FORMTEXT ?????Describe any situation in which your dog seems fearful and may resort to using aggression: FORMTEXT ?????OTHER PROBLEMS: Check any unwanted behaviors that your dog exhibits.Jumping up ?Tail chasing/spinning ?Excessive grooming/chewing ?Mounting/humping ?Pulling on leash ?Light/shadow chasing ?Excessive licking of surfaces ?Escaping house/yard ?Excessive barking ?House-soiling, Urine ?Stool eating ?Digging ?House-soiling, Feces ? Stealing/chewing items ?Describe any unwanted problems in greater detail. FORMTEXT ?????TRAINING HISTORY AND HOME ENVIRONMENTCLASSESHas your dog had any FORMAL obedience training? FORMTEXT ????? Success at training: POOR ? FAIR ? MODERATE ? EXCELLENT ?What commands does your dog respond to? FORMTEXT ?????Which family member does your dog respond to the best? FORMTEXT ?????Have you and your dog worked with a trainer for any behavioral problems?Trainer’s name/company name: FORMTEXT ?????Behavioral problem addressed: FORMTEXT ?????Methods used, if known: FORMTEXT ?????Did the problem improve? FORMTEXT ?????TRAINING TOOLS AND EQUIPMENTWhat training tools/equipment have you used in the past and which do you currently use? TypeUsed in PastCurrently UseCommentsClicker Yes ? No ?Yes ? No ? FORMTEXT ?????Verbal praiseYes ? No ?Yes ? No ? FORMTEXT ?????Food reward Yes ? No ?Yes ? No ? FORMTEXT ?????Choke chainYes ? No ?Yes ? No ? FORMTEXT ?????Prong collarYes ? No ?Yes ? No ? FORMTEXT ?????Electronic/shock collarYes ? No ?Yes ? No ? FORMTEXT ?????Citronella collarYes ? No ?Yes ? No ? FORMTEXT ?????Head halterYes ? No ?Yes ? No ? FORMTEXT ?????Front clip harnessYes ? No ?Yes ? No ? FORMTEXT ?????Rear clip harnessYes ? No ?Yes ? No ? FORMTEXT ?????Front clip harnessYes ? No ?Yes ? No ? FORMTEXT ?????Martingale collarYes ? No ?Yes ? No ? FORMTEXT ?????Flat collarYes ? No ?Yes ? No ? FORMTEXT ?????Retractable leashYes ? No ?Yes ? No ? FORMTEXT ?????FOOD AND TOY MOTIVATIONItem Brand/typeHow often given?Motivation for this Dog food (canned) FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Dog food (dry) FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Table scraps/people food FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Treats (Milkbone, etc.) FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?High value chews (rawhides, etc.) FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Balls FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Stuffed animals FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Chew toys (Nylabone, etc.) FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Does your pet have any food allergies? FORMTEXT ????? If so, to what? FORMTEXT ?????Does your pet have a favorite toy or game? FORMTEXT ?????ACTIVITIES AND EXERCISE SituationAmount of time per day or week Location (bedroom, yard, crate, etc.)In house, per day FORMTEXT ????? FORMTEXT ?????In yard, per day FORMTEXT ????? FORMTEXT ?????Leash walks FORMTEXT ????? FORMTEXT ?????Leash runs, jogging FORMTEXT ????? FORMTEXT ?????Off leash exercise FORMTEXT ????? FORMTEXT ?????Playtime FORMTEXT ????? FORMTEXT ?????Sleeping during day FORMTEXT ????? FORMTEXT ?????Sleeping at night FORMTEXT ????? FORMTEXT ?????Do you have a fenced yard? Yes ? No ? If yes, what type of fence? FORMTEXT ????? Approximate height? FORMTEXT ?????Please describe your home: House ? Townhouse ? Apartment/condo ? Number of floors: FORMTEXT ?????Please describe your neighborhood: Urban ? Suburban ? Rural ?MEDICAL HISTORYIs your pet up to date on routine vaccinations, including rabies? YES ? NO ?MEDICATIONList any medications or supplements your dog currently receives. Please include flea, tick, and heartworm prevention.Name of MedicationDose (mg) or amountHow oftenReason Given FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MEDICAL PROBLEMSPlease list any medical problems your pet has had (attach an additional sheet if necessary).ProblemDates if known On going FORMTEXT ????? FORMTEXT ?????YES ? NO ? FORMTEXT ????? FORMTEXT ?????YES ? NO ? FORMTEXT ????? FORMTEXT ?????YES ? NO ? FORMTEXT ????? FORMTEXT ?????YES ? NO ?Thank you for taking the time to fill out this form. ................
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