SF SPCA Behavior Specialty Service General Dog History Form

SF SPCA Behavior Specialty Service General Dog History Form

Please complete and return via email, fax, or in person at least three days before your appointment.

E-mail:

Fax: 415-962-2495

201 Alabama Street, San Francisco CA 94103

Client Name:

Pet Name:

Your regular veterinarian’s name and location:

Please tell us how you were referred to our practice:

Due to time constraints, during the appointment we will focus on one or two behavior problems. We can make note of other unwanted behaviors to address at a later date, but the initial consultation will be geared toward assessing, diagnosing, and explaining your options to improve your dogs’ main or most serious behavior problem.

What is your primary goal for this appointment?

Pet Acquisition Background

How old was your dog when you first acquired him or her?

Where did you obtain your dog?

Primary Problem Statement: Briefly describe the main behavior problem that you would like us to help (for example: when he’s on leash, my dog growls and then snaps at people walking by).

Secondary Problem Statement: Briefly describe the secondary problem that you would like us to help.

Please answer all the following questions relating to the primary problem, not the secondary problem.

How long has the primary problem been occurring?

How old was your dog when it started?

When the primary problem first occurred, what type of body language did your dog exhibit? Check all that apply.

Freeze / Ears back / Lunge / Run away
Hide / Eats erect / Snap / Tremble
Stare / Whine / Bite / Hackles raised
Tail Up / Growl / Charge / Tail stiff
Tail Down / Bark / Cower / Tail wagging

Has the behavior increased, decreased, or stayed the same?

Frequency

How frequently does the problem occur? Circle one:

1-10 times/day >10 times/day 1-6 times/week <1x/week <1 time/month

Is this frequency increasing, decreasing, or staying the same?

If your dog is in a potentially problematic situation, what percentage of the time does the behavior occur? Circle one:

<25% 25%-50% 51%-75% 76%-100%

Do the behavior problems occur at particular times of the day or night? Explain:

Attempts to Solve

How have you addressed the problem? Check all that apply.

Avoided exposure
Treats
Verbal corrections (yelling, scolding)
Squirt bottle
Shock or vibration collar
Physical corrections (leash corrections, hitting, shaking, rolling over)
Hired professional help
Name of trainer/behaviorist:
Sent for board and train
Location:
What was your dog's response to each?

Biting

Describe the worst bite that your dog caused, to a person or another dog, as a result of the primary problem (if applicable, check all that apply):

Made contact, but no mark
Small red mark
Bruised, didn't break skin
Broke skin, minor scrape
Broke skin, punctures
Broke skin, multiple punctures
Punctures and tore flesh
Multiple bites at one time
Required ER treatment

Describe the situation that led to the bite:

Have any victims threatened or taken legal action because of an aggressive incident? YES NO

Was quarantine required by animal control because of the bite? YES NO

Were any judge ordered legal actions taken? YES NO

Other Problems

Note any other problem behaviors and their frequency.

Activity / No / When you are present
(times / week) / When you are not present (times / week) / Do not know
House soiling / ¨ / (_____ / _____) / (_____ / _____) / ¨
Excessive barking/whining / ¨ / (_____ / _____) / (_____ / _____) / ¨
Destructive chewing / ¨ / (_____ / _____) / (_____ / _____) / ¨
Digging / ¨ / (_____ / _____) / (_____ / _____) / ¨
Self licking/chewing / ¨ / (_____ / _____) / (_____ / _____) / ¨
Pacing/repetitive behavior / ¨ / (_____ / _____) / (_____ / _____) / ¨
Consuming non-food object / ¨ / (_____ / _____) / (_____ / _____) / ¨
Circles/chasing tail/freezing / ¨ / (_____ / _____) / (_____ / _____) / ¨

Household Information

Which best describes your residence type?

Apartment
House
Condo

Which best describes your neighborhood?

Urban
Suburban
Rural

If you have a yard, what is the approximate size (acreage)?

If your yard has a fence, please check all that apply:

Less than 6 feet tall
More than 6 feet tall
Wood
Chain link
Brick

Since you’ve owned your dog, how many residences has the dog lived in?

Please list all people who interact with your dog on a regular basis, and rate their response to the dog’s unwanted behaviors: mild, moderate, or severe

Name / Age (optional) / Relationship / Response

List all household pets in the order that they came into the household

Pet Name / Species / Breed / Age / Sex / Relationship

Background information

What made you choose this particular dog?

If known, how did the littermates differ from your dog? (e.g.; too pushy, too playful, too rough with other littermates)

Check all options that describe your dog when you first acquired him or her

Friendly to family members / Shy with strangers / Aloof
Aggressive to family members / Extremely submissive / Anxious
Aggressive to strangers / Happy, outgoing / Hyper excitable
Friendly to strangers / Fearful of environment / Inhibited
Fearful of noises / Do not know
Other (describe):

Describe the personality of your dog today by checking all that apply

Friendly to family members / Shy with strangers / Aloof
Aggressive to family members / Extremely submissive / Anxious
Aggressive to strangers / Happy, outgoing / Hyper excitable
Friendly to strangers / Fearful of environment / Inhibited
Fearful of noises / Do not know
Other (describe):

Spay/Neuter Information

Is your dog spayed or neutered? YES NO

If YES, did you notice a change in behavior after the surgery? Describe:

Medical History

List all medications (including flea and heartworm preventives), dosage, frequency of dose, and date started.

List any major illnesses or surgeries, past and current (if any).

List all current medical problems (if any).

Daily Activities and Routine

How often is your dog fed? Circle all that apply: Once/day Twice/day Free fed

What does your dog eat from? Circle all that apply: Bowl Kibble dispenser Kongs Other toys

Who usually feeds the dog?

Have there been any major changes to the dog’s daily routine (e.g.; vacation, owner who travels frequently for business, etc.)? If so, describe:

Eating Habits

Check all that describe your dog’s eating habits:

Eats right away / Anxious eater / Guards food from people
Picky eater / Guards food from dogs
Other (describe):

If you give your dog treats, please list the type and situation:

Sleeping Habits

Where does your dog sleep during the day?

Where does your dog sleep at night?

Does your dog react negatively when disturbed while sleeping? YES NO How often?

Leashed Exercise

Does your dog get regular leash walks? YES NO How often?

Do you have trouble walking your dog on leash (e.g.; pulls, stalls, lunges at other dogs)? If so, describe:

Who takes your dog for leashed walks?

How long are the walks?

Where are the walks (e.g.; around the neighborhood, in town, at the park)?

What equipment is used to walk your dog? Check all that apply:

Front buckle collar / Prong collar
Front buckle body harness / Short leash (less than 4 ft)
Head collar (Gentle Leader) / Long leash (6+ ft)
Training / choke collar / Average Leash (4-6 ft)
Retractable leash / Other (describe):

Play

In order of preference, list five items your dog likes:

1.

2.

3.

4.

5.

Who plays with your dog the most (e.g.; you, relative, child, another dog):

How often does your dog play with toys?

Several times per day / Once daily / Several times per week
Weekly or rarely / Never

How often does your dog play with people?

Several times per day / Once daily / Several times per week
Weekly or rarely / Never

How often does your dog play with other dogs?

Several times per day / Once daily / Several times per week
Weekly or rarely / Never

Living Spaces / Being Left Alone

Where does your dog spend the most time when people are at home?

Loose in the house Does your dog also have outdoor access?
Confined to a part of the house Does your dog also have outdoor access?
Inside a crate or pen
Loose in the yard
Outside in a kennel or pen
Other (describe):

When is your dog left alone (e.g.; 8am – 5pm Monday through Friday):

What is your dog’s reaction to being left alone? Check all that apply.

Calm / Cries/howls / Urinates / defecates
Depressed / Excited / Destructive
Barks / Escapes / Anxious
Aggressive

Where does your dog spend time when people are not at home?

Loose in the house Does your dog also have outdoor access?
Confined to a part of the house Does your dog also have outdoor or potty access?
Inside a crate or pen
Loose in the yard
Outside in a kennel or pen
Other (describe):

Training

Has your dog had any formal training? YES NO

If yes, please list the training information.

Dates / Length of Class / Type of Training Class / Instructor / School

What training tools have you used? Check all that apply.

Clicker training / Choke chain
Food rewards / Electronic collar
Others (describe):

If your dog was informally trained, who in the household trained your dog?

Please note if your dog understands the below commands.

Command / Cue / Percent of time dog obeys without distractions / Percent of time dog obeys with distractions / Are you happy with dog’s responsiveness?
Sit
Down
Stay
Recall (come)
Retrieve (fetch)
Give (drop)
Look
Touch
Shake
Other

Situational Assessment: Please check all that apply to your dog’s behavior in the following situations. Leave box blank if you do not know.

Activity / Situation
In the home / Happy / Neutral / Fearful / Anxious / Bark or Growl / Snap or Bite
Unfamiliar people at door / ¨ / ¨ / ¨ / ¨
Unfamiliar people in home / ¨ / ¨ / ¨ / ¨
Dog in yard, another dog passes by / ¨ / ¨ / ¨ / ¨
Dog in yard, person passes by / ¨ / ¨ / ¨ / ¨
Family member reaches over, pets dog on head / ¨ / ¨ / ¨ / ¨
Family member lifts dog up / ¨ / ¨ / ¨ / ¨
Take away food dish while dog is eating / ¨ / ¨ / ¨ / ¨
Take away bone/toy/object / ¨ / ¨ / ¨ / ¨
Nail trimming / ¨ / ¨ / ¨ / ¨
Grooming/bathing / ¨ / ¨ / ¨ / ¨
Wiping feet / ¨ / ¨ / ¨ / ¨
Vacuum cleaner / ¨ / ¨ / ¨ / ¨
Broom / ¨ / ¨ / ¨ / ¨
Behavior toward other household dog(s)/cat(s) / ¨ / ¨ / ¨ / ¨
Disturbed while sleeping / ¨ / ¨ / ¨ / ¨
Roughhousing / ¨ / ¨ / ¨ / ¨

Noises and moving objects outside or inside the home / Happy / Neutral / Fearful / Anxious / Bark or Growl / Snap or Bite
Loud noises, motorcycles, horns, sirens, metal banging, backfires / ¨ / ¨ / ¨ / ¨
Buses/trucks passing by, on leash / ¨ / ¨ / ¨ / ¨
Squirrels, cats, small animals approaching dog / ¨ / ¨ / ¨ / ¨
Bicycles, joggers, skateboards / ¨ / ¨ / ¨ / ¨
Thunder / ¨ / ¨ / ¨ / ¨
Car rides / ¨ / ¨ / ¨ / ¨
Dogs outside of the home / Happy / Neutral / Fearful / Anxious / Bark or Growl / Snap or Bite
Unfamiliar dogs, on leash / ¨ / ¨ / ¨ / ¨
Unfamiliar dogs, off leash / ¨ / ¨ / ¨ / ¨
Playing with unfamiliar dogs off leash / ¨ / ¨ / ¨ / ¨
People outside of the home / Happy / Neutral / Fearful / Anxious / Bark or Growl / Snap or Bite
Unfamiliar people reaching toward dog while on leash / ¨ / ¨ / ¨ / ¨
Unfamiliar people reaching toward dog while off leash / ¨ / ¨ / ¨ / ¨
Unfamiliar people walking by while dog is on leash / ¨ / ¨ / ¨ / ¨
Unfamiliar people walking by while dog is off leash / ¨ / ¨ / ¨ / ¨
Stranger approaches when dog is inside car / ¨ / ¨ / ¨ / ¨
Stranger staring at dog / ¨ / ¨ / ¨ / ¨
Children reaching for dog / ¨ / ¨ / ¨ / ¨
Children in general / ¨ / ¨ / ¨ / ¨
Response to corrections / Happy / Neutral / Fearful / Anxious / Bark or Growl / Snap or Bite
Grasping collar, restraining dog / ¨ / ¨ / ¨ / ¨
Verbal reprimand / ¨ / ¨ / ¨ / ¨
Physical reprimand / ¨ / ¨ / ¨ / ¨
Leash correction / ¨ / ¨ / ¨ / ¨

Have anyone ever suggested euthanizing or re-homing your dog because of the behavior problem? YES NO

Have you ever considered euthanizing or re-homing your dog because of the behavior problem? YES NO

I, have read the policies and procedures put forth above and understand them fully. I agree to adhere to these policies as a client of the San Francisco SPCA Veterinary Hospital.

Signed: Date:

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