1

CANINE BEHAVIORAL HISTORY FORM This 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 INFORMATION CLIENT INFORMATION

Last Name: First Name: Street Address: City: State: Zip: Home Phone: Cell Phone: E-mail address: Spouse/Partner First Name: Last Name:

PET INFORMATION

Name: Breed: Color: Date of birth: Age: Weight: Sex: Male (intact) ☐ Male (neutered) ☐ Female (intact) ☐ Female (spayed) ☐ Age when obtained: Age neutered or spayed: Where did you obtain this dog? BREEDER ☐ PET STORE ☐ ANIMAL SHELTER ☐ RESCUE ☐ FRIEND ☐ OTHER

VETERINARY INFORMATION

Your primary veterinarian’s name: Name of Clinic or Hospital: City: State: Office Phone: Fax: Email:

How did you hear about the Carolina Veterinary Behavior Clinic?

HOUSEHOLD INFORMATION PERSONS LIVING IN THE HOUSEHOLD

Name Age Sex Hours Away from Home Interaction with pet M ☐ F ☐ M ☐ F ☐ M ☐ F ☐ M ☐ F ☐ M ☐ F ☐

Carolina Veterinary Behavior Clinic Dr. Jillian Orlando, DVM, DACVB

409 Vick Avenue Raleigh, NC 27612

Phone: (919) 791-9058 Fax: (919) 324-3822

appointments@carolinavetbehavior.com

2

PETS LIVING IN THE HOUSEHOLD

Name Species Breed Age Sex Weight Interaction with patient pet

BEHAVIORAL PROBLEMS Please list your pet’s top 3 behavioral problems that you would like to address: 1.

2.

3.

What are your goals for treatment? Have you considered euthanasia? YES ☐ NO ☐ Please comment:

Describe the worst two incidents in as much detail as possible.

1.

2.

How would you describe the severity of this problem? MILD ☐ MODERATE ☐ SEVERE ☐ How often does this problem occur? Total number of times this has occurred?

How would you describe the severity of this problem? MILD ☐ MODERATE ☐ SEVERE ☐ How often does this problem occur? Total number of times this has occurred?

How would you describe the severity of this problem? MILD ☐ MODERATE ☐ SEVERE ☐ How often does this problem occur? Total number of times this has occurred?

Date: Incident:

Date: Incident:

3

PROBLEM BEHAVIOR HISTORY How old was your pet when the problem(s) began? Were there changes in the home at that time? What do you think is the reason for your dog’s problem?

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.

2.

3.

4.

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.

2.

3.

4.

PUNISHMENTS Indicate any correction techniques you have used and indicate their effects on your dog’s behavior.

Type Have you Tried?

Improved Problem No Effect Made

Worse Comments

Time out Yes ☐ No ☐ ☐ ☐ ☐

Leash jerks Yes ☐ No ☐ ☐ ☐ ☐

Verbal scolding Yes ☐ No ☐ ☐ ☐ ☐

Noisemaker Yes ☐ No ☐ ☐ ☐ ☐

Water bottle Yes ☐ No ☐ ☐ ☐ ☐

Spanking/smacking Yes ☐ No ☐ ☐ ☐ ☐

Forced alpha roll Yes ☐ No ☐ ☐ ☐ ☐

Other Yes ☐ No ☐ ☐ ☐ ☐

SPECIFIC BEHAVIORAL HISTORY/SCREENING HANDLING Check how your dog responds to the following tasks:

TASK NO REACTION

AVOIDS RESISTS GROWLS SNAPS COMMENTS

Trimming nails ☐ ☐ ☐ ☐ ☐

Giving pill ☐ ☐ ☐ ☐ ☐

Cleaning ears ☐ ☐ ☐ ☐ ☐

Grooming ☐ ☐ ☐ ☐ ☐

Bathing ☐ ☐ ☐ ☐ ☐

Patting Head ☐ ☐ ☐ ☐ ☐

4

TASK NO REACTION

AVOIDS RESISTS GROWLS SNAPS COMMENTS

Grasping Collar

☐ ☐ ☐ ☐ ☐

Being Lifted ☐ ☐ ☐ ☐ ☐

Rolling Over ☐ ☐ ☐ ☐ ☐

AGGRESSION Indicate your dog’s response to the following situations. Check all that apply.

NoResponse

Freezes/Stares

Task n/a Barks Growls Lifts Lip

Snaps/ Bites

Comments

When dog is approached while eating

☐ ☐ ☐ ☐ ☐ ☐ ☐

When approached while chewing a high value treat/toy

☐ ☐ ☐ ☐ ☐ ☐ ☐

When taking away a stolen object or high value treat/toy

☐ ☐ ☐ ☐ ☐ ☐ ☐

When dog is scolded ☐ ☐ ☐ ☐ ☐ ☐ ☐

When dog is spanked ☐ ☐ ☐ ☐ ☐ ☐ ☐

When dog is pushed off furniture (bed, couch)

☐ ☐ ☐ ☐ ☐ ☐ ☐

When dog is approached while resting/sleeping

☐ ☐ ☐ ☐ ☐ ☐ ☐

Ever, to family members ☐ ☐ ☐ ☐ ☐ ☐ ☐

To strangers in the yard or at the door

☐ ☐ ☐ ☐ ☐ ☐ ☐

To strangers entering house ☐ ☐ ☐ ☐ ☐ ☐ ☐

Ever, to children or infants ☐ ☐ ☐ ☐ ☐ ☐ ☐

While in car, to persons outside car

☐ ☐ ☐ ☐ ☐ ☐ ☐

To painful stimuli (injection or removing tick)

☐ ☐ ☐ ☐ ☐ ☐ ☐

To familiar dogs in your home

☐ ☐ ☐ ☐ ☐ ☐ ☐

To unfamiliar dogs outside your home

☐ ☐ ☐ ☐ ☐ ☐ ☐

5

Describe any situation in which your dog is muzzled for safety:

Describe any situation in which you are, or any family member is, afraid of your dog:

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?

BITE HISTORY

TYPE OF BITE Has

Occurred To a Dog

To a Human

Total # of Incidents

COMMENTS

Snapped at, no contact ☐ ☐ ☐ Made contact, no mark ☐ ☐ ☐ Small red mark ☐ ☐ ☐ Bruised, no broken skin ☐ ☐ ☐ Broke skin, minor scrape ☐ ☐ ☐

Puncture ☐ ☐ ☐ Multiple punctures ☐ ☐ ☐ Laceration, torn flesh ☐ ☐ ☐

Severe mutilation, death ☐ ☐ ☐ Required ER treatment ☐ ☐ ☐

ATTACHMENT AND SEPARATION ANXIETY

When you are home, does your dog follow you from room to room?

Does your dog always insist on lying on or near you? Does your dog become anxious if left inside the house while you are in the yard?

Does your dog become anxious if closed outside of the bathroom while you shower, etc.?

How often is your dog left home alone (no people in the house)? For how many hours is your dog alone? What is your pet’s reaction to your routine departures (eg. Going to work or school daily)?

What is your pet’s reaction to unexpected departures (eg. Going out to dinner, running an errand)?

What is your pet’s reaction to your return home?

If your dog shows anxiety when household members leave:

Do they show anxiety when any member leaves even if others are still home?

Do they only show anxiety when the last person leaves the house (being left alone)?

Do they only show anxiety when a specific person leaves and ignores other people leaving?

6

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? What is your dog’s behavior while crate (ex. tries to escape, sleeps, etc.)?

Where in the home is your dog’s crate located? 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)? If so, where?

If so, what barrier is used to keep him/her confined (ex. closed door, baby gate, etc.)?

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.:

FEAR AND ANXIETY

How does your dog react to thunderstorms?

How does your dog react to light rain/mild storms?

How does your dog react to fireworks? How does your dog react to other loud noises (gunshots, engine backfire, etc.)?

Does your dog react fearfully to loud kitchen appliances or the vacuum cleaner?

Does your dog react fearfully to riding in the car?

Does your dog react fearfully to going places (vet’s, pet store, friend’s house)?

Please list what anxious behaviors your dog shows during specific situations (including the ones mentioned above):

Signs of anxiety Situations in which it occurs Cowering Trembling Ears back Tail tucked Retreating/backing away Hiding (under bed, behind couch) Whining/crying in distress Excessive panting Drooling Pacing

7

Please make any additional comments regarding fear or anxiety in your dog:

Describe any situation in which your dog seems fearful and may resort to using aggression:

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 the unwanted problems in greater detail.

TRAINING HISTORY AND HOME ENVIRONMENT CLASSES

Has your dog had any FORMAL obedience training? Success at training: POOR ☐ FAIR ☐ MODERATE ☐ EXCELLENT ☐ What commands does your dog respond to? Which family member does your dog respond to the best? Have you and your dog worked with a trainer for any behavioral problems? Trainer’s name/company name: Behavioral problem addressed: Methods used, if known: Did the problem improve?

TRAINING TOOLS AND EQUIPMENT What training tools/equipment have you used in the past and which do you currently use?

Type Used in Past Currently Use Comments

Clicker Yes ☐ No ☐ Yes ☐ No ☐ Verbal praise Yes ☐ No ☐ Yes ☐ No ☐ Food reward Yes ☐ No ☐ Yes ☐ No ☐ Choke chain Yes ☐ No ☐ Yes ☐ No ☐ Prong collar Yes ☐ No ☐ Yes ☐ No ☐ Electronic/shock collar Yes ☐ No ☐ Yes ☐ No ☐ Citronella collar Yes ☐ No ☐ Yes ☐ No ☐ Head halter Yes ☐ No ☐ Yes ☐ No ☐ Front clip harness Yes ☐ No ☐ Yes ☐ No ☐ Rear clip harness Yes ☐ No ☐ Yes ☐ No ☐ Front clip harness Yes ☐ No ☐ Yes ☐ No ☐ Martingale collar Yes ☐ No ☐ Yes ☐ No ☐ Flat collar Yes ☐ No ☐ Yes ☐ No ☐ Retractable leash Yes ☐ No ☐ Yes ☐ No ☐

8

FOOD AND TOY MOTIVATION Item Brand/type How often given? Motivation for this

Dog food (canned) mild ☐ moderate ☐ strong ☐ Dog food (dry) mild ☐ moderate ☐ strong ☐ Table scraps/people food mild ☐ moderate ☐ strong ☐ Treats (Milkbone, etc.) mild ☐ moderate ☐ strong ☐ High value chews (rawhides, etc.) mild ☐ moderate ☐ strong ☐ Balls mild ☐ moderate ☐ strong ☐ Stuffed animals mild ☐ moderate ☐ strong ☐ Chew toys (Nylabone, etc.) mild ☐ moderate ☐ strong ☐

Does your pet have any food allergies? If so, to what? Does your pet have a favorite toy or game?

ACTIVITIES AND EXERCISE

Situation Amount of time per day or week Location (bedroom, yard, crate, etc.) In house, per day In yard, per day Leash walks Leash runs, jogging Off leash exercise Playtime Sleeping during day Sleeping at night

Do you have a fenced yard? Yes ☐ No ☐ If yes, what type of fence? Appr height? Please describe your home: House ☐ Townhouse ☐ Apartment/condo ☐ Number of floors: Please describe your neighborhood: Urban ☐ Suburban ☐ Rural ☐

MEDICAL HISTORY Is your pet up to date on routine vaccinations, including rabies? YES ☐ NO ☐ MEDICATION List any medications or supplements your dog currently receives. Please include flea, tick, and heartworm prevention.

Name of Medication Dose (mg) or amount How often Reason Given

9

MEDICAL PROBLEMS Please list any medical problems your pet has had (attach an additional sheet if necessary).

Problem Dates if known On going YES ☐ NO ☐ YES ☐ NO ☐ YES ☐ NO ☐ YES ☐ NO ☐

Please use this space to give an additional information you would like to share:

Thank you for taking the time to fill out this form.

Rev 09/2018