CANINE BEHAVIOUR CONSULTATION QUESTIONNAIRE



CANINE BEHAVIOR CONSULTATION QUESTIONNAIRE

Oakland Veterinary Referral Services

1400 S. Telegraph Rd, Bloomfield Hills, MI 48302

Theresa L. DePorter, DVM, MRCVS, DECAWBM, DACVB

Veterinary Behaviorist

Resident in Veterinary Behavior Medicine

Dr Katrin Jahn, DrMedVet, CertVA, MRCVS, ACVB & ECAWBM

German Veterinary Clinic Khalifa City A, Abu Dhabi, UAE

General Information

Today’s date:      

Date and time of consultation (if scheduled):      

Name:      

Email:      

Address:      

City/Town:          

Zip Code:      

Phone: Home: (      )      

Mobile/other: (      )      

What is the best means of contacting you?     

Veterinary Clinic:     

Veterinarian’s Name:      

Clinic phone: (     )     

Who referred you?      

This questionnaire is being completed by:      

Pet Information

Pet’s name:      

Breed or description:      

Date of birth:      

Age:      

Sex:      

Spayed/neutered?       If yes, when?      

Color:      

Weight:      

Describe your dog’s personality:      

Your Pet’s Early History

Age obtained:      

Date obtained:      

For what reason did you obtain this pet?

     

Describe where you obtained your dog and/or their previous type of home/s:

(Include the name of breeder/website/advertisement, rescue group/shelter/foster home(s), for how long, with whom, why relinquished and any other details you may think relevant)

     

Give any information about your dog’s parents or littermates? (Include whether you met the parents, their behaviour and health status as well as any information about the behaviour of the siblings)

     

The Home Environment

List each family member in the home (Include yourself, children and/ or frequent visitors):

|Name |Occupation |Family relationship |Sex |Age |Describe how they get |Present |

| | | | | |along with dog |for the consult |

|      |      |      |      |      |      | |

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Who else has regular contact with your dog? (Friends, neighbours, walker, groomer, trainer, day care etc.)

     

List all other pets in the home:

|Name |Breed |Sex |Neutered/spayed? |Age |Describe how they get along with this dog |

|      |      |      |      |      |      |

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Please let us know how you feel* about using medications for your pet’s behavior problem:

I wish to use behavior modification alone to improve my pet’s behavior

I wish to use behavior modification alone but will consider using medication if it is recommended

I wish to use a combination of behavior modification and medications to improve my pet’s problem

I wish to use a combination of behavior modification & natural supplements to improve my pet’s problem

I fully anticipate using medications to improve my pet’s problem

* Your preferences will be considered as the doctor recommends the approach that best fits your pet’s behavior problem.

Describe your goals and expectations for your dog’s behavior

     

Describe your goals and expectations for this behavior consultation

     

How would a change in your dog’s behavior impact your life?

     

Describe how you learn best:

     

Diet and Nutrition

Describe your dog’s meals and feeding routine (including who feeds the dog, where your dog is fed, what you feed and how quickly the food is eaten)

Describe type of treat(s) and when you give them

     

What is your dog’s absolute favourite treat?      

Does your dog have any food allergies? Yes No

IF YES, PLEASE BRING TREATS THAT YOUR DOG CAN EAT TO THE BEHAVIOR APPOINTMENT

Medical Information

Describe any current, pre-existing or ongoing medical problems:

     

List ALL medication/supplements your pet receives currently or frequently (Behavior and Non-Behavior):

|Medication |Strength |How often given |When started |Purpose |

|      |      |      |      |      |

|      |      |      |      |      |

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Describe laboratory tests (Include blood, urine, x-rays, etc and date performed):

     

When was the last time your dog was seen by a veterinarian?

Date:      

Reason:      

Activities

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

Midnight – 4 am      

4 am – 8 am      

8 am – 12 noon      

12 noon – 4 pm      

4 pm – 8pm      

8 pm – midnight      

Is there anything else we should know about your dog’s daily/weekly/monthly routine?

     

What percentage of time does your dog spend indoors vs outdoors?

% indoors      % outdoors     

• Favorite play/game(s)/toy(s):      

• Describe your dog’s preferred sleeping spot during the day      

• Where does your dog sleep at night?      

• Does your dog wake you up at night? Yes No Describe:      

How would you describe your pet’s maintenance activities?

| |Normal/ appropriate |Decreased |Excessive |New Change? |

|      |      |      |      |      |

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Your pet’s behavior consultation

Is there anything else you would like to add about your pet and its behavior? Include any other information you think is relevant to the case or your family.

     

Thank you for completing this form!

You have taken an important step toward resolving your pet’s behavior problem!!

This questionnaire was designed by Dr Theresa DePorter and Dr Katrin Jahn and may be reproduced only with written permission.

They retain all rights to the use of this questionnaire – it may not be modified, distributed, reproduced, posted online or used commercially.

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