Perth Veterinary Behaviour Service
The missing piece of puzzling behaviour
0450 847 226
ABN 93 381 642 127
Canine Behavioural History
Please answer the following questions as completely as possible and return it to me a few days before your consultation. If possible, please take some video footage of your dog in everyday situations. This should be “a day in the life of” your pet: where it sleeps, eats and plays. It should NOT contain episodes of aggression if that is the problem you are seeing us for.
The completed behaviour questionnaire helps me to assess the environment, social interactions and behaviour of your dog, allowing me to determine the possible cause(s), prognosis and specific treatment protocol for their problem(s).
The consultation will focus on specific areas from the questionnaire and involves a behavioural assessment of your pet. The consultations will normally be between 1.5-2 hours long. Please bring some of your dog's favourite food treats and toys.
GENERAL INFORMATION
Your name:
Address:
Post Code:
Home Ph: Work Ph:
Mobile Ph: Fax:
Email:
Pet's Name:
Breed:
Date of Birth: Age:
Weight:
Sex:□ Male□ FemaleDesexed:□ Yes□ No
How did you hear about us?
Who referred you to us?
Who is your regular Veterinarian? Dr:
Clinic Name:
Address:
Phone:
Fax:
Email:
What is the main reason for consultation?
Are there any other behaviour problems?
Please give the name, age and occupation (where applicable) of people living in your household (include ages of children).
Name / Occupation / Hours Away From Home / AgePlease list all of the animals in your household (including the one you are bringing in to see us).
Name / Species / Breed / Sex/Desexed / Age Obtained / Age NowIn what order were the above animals obtained? (Please number them in the above table)
Has the situation in your household changed since acquiring your dog?
□ Yes□ No
How? (Please circle)
Newborn babyDeath of a petNew pet
Death of a family memberChanged routine (new job/loss of job/altered work hours)
Child movedFamily moved Divorce
MarriageOther
Do you have any physical ailments that influence your ability to interact with your dog?
DOG'S BACKGROUND
Where did you get this dog and at what age? Age:
□ Friend□ Stray□ RSPCA/Shelter
□ Pet Store□ Breeder – Newspaper ad□ Breeder – Referral
□ Other
How many animals did you have to choose from?
Why did you choose this particular dog over others?
If known, how many littermates were there? Males: Females:
Did you meet your dog's parents?
Mother:□ Yes□ NoFather:□ Yes□ No
If yes, please describe their behaviour?
Mother:
Father:
Why did you choose to get a dog?
Why did you choose this particular breed?
Describe your dog's behaviour as a puppy, if known.
Do you know anything about the behaviour of littermates or parents?
Do they have any behaviour problems (please describe)?
Has your dog had any previous owners?□ Yes □ No
If yes, how many?
Why was the dog given up?
Have you owned a pet before owning this dog?□ Yes□ No
Have you owned dogs before? □ Yes □ No
If so, what happened to your last dog?
MEDICAL HISTORY
If your dog is sterilised please answer the following three questions (please move to the next question if your dog is not sterilised):
At what age was your dog neutered/spayed?
Why was this done?
Were there any behaviour changes after neutering? (Please describe)
If your dog has NOT been sterilised please answer the following three questions (please move to the next question if your dog is sterilised):
Has your dog ever been bred? □ Yes□ No
Are you planning to breed?□ Yes□ No□ Unsure
If you have an entire female, when was her last heat?
Please provide a brief medical history (please include any prescribed medications, herbal/alternative treatments, dietary supplements etc. that have been tried or are currently used, including dosage and frequency).
DIET AND FEEDING
Who feeds the dog?
When and where do you feed the dog?
What do you feed your dog? (Please include brand name, quantity and if you feed any extra food such as scraps, treats, bones etc.)
Does your dog eat all his/her food at once?□ Yes□ No
If you answered no, how long do you leave it down?
Where is the dog when you eat?
Does your dog beg for food?
Can you remove food, toys or bones safely from your dog? If you answer no, describe your dog's reaction (please do not attempt to do so if you have any concerns about your dog's reaction).
List your dog's favourite food treats in order of preference.
HOME ENVIRONMENT
How much time does your dog spend indoors/outdoors?
Indoors % Outdoors %
On average, how many hours does your dog spend being active each day?
Who exercises the dog?
How long per walk?
How many times per day?
How many days per week?
What is your dog's level of activity? (Please circle)Low Medium High Excessive
What percentage of time does your dog spend on the following activities?
On Lead
Supervised Off Lead
Free Roaming
In Yard
Playing Outdoors
Playing Indoors
Tied up or run
Describe your dog's typical daily routine over a 24-hour period (sleeping, feeding, exercise etc.)
Midnight
1am
2am
3am
4am
5am
6am
7am
8am
9am
10am
11am
12pm (noon)
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
10pm
11pm
What is your typical daily routine?
What type of area do you live in?
□ City/Town □ Suburbs□ Rural
What type of house do you live in?
□Unit□ Townhouse□ House with small/medium yard
□ House with big yard□ Acreage□ Other:
Have you moved since acquiring your dog? If so, how many times?
How long since the last move?
GENERAL BEHAVIOUR
Is your dog housetrained, if so, how did you achieve this?
Does your dog ever eliminate in the house? □ Yes□ No
If yes, is it urine, faeces or both?
Where and when does the elimination occur?
How often does the elimination occur?
Please complete the following table:
Location / Why?Where does your dog sleep at night?
Where is your dog when you have guests?
Where is your dog when left in the house alone?
Describe in detail your routine as you prepare to leave the house when your dog will be left alone.
Describe how your dog behaves when you are leaving the house.
Describe how your dog behaves when you return home.
Does your dog's level of excitement reflect your length of absence? (i.e. is he/she more excited the longer you are away?)
How does your dog behave during thunderstorms or to fireworks?
Does your dog react to other noises? If so, please explain.
What sort of toys does your dog have?
What is your dog’s favourite toy?
What games does your dog like to play?
How would you describe your relationship with your dog?
MANNERS AND BEHAVIOUR
Does your dog do any of the following (please tick which apply):
YES / NOJump up on you without permission?
Jump up on other people without permission?
Paw at you?
Paw at other people?
Mount you?
Mount other people?
Mount other dogs or objects?
Bark at you?
Bark at other people?
Bite, lick or groom himself/herself excessively?
If you ticked yes for any of the questions in the above table, please describe the situation.
How does your dog react with the following:
other dogs?
strangers?
children?
friends?
groomers?
veterinarian?
How does your dog get along with other pets in your household, if applicable?
Do you have any other comments about your dog's behaviour?
TRAINING
Have you done any training (formal or informal) with your dog? If so, please explain (where, when, which trainer, how long for, what type of training etc.)
Who is the primary trainer?
Why did you take your dog training?
Did you find it helpful? Why or why not?
How did your dog behave during training classes?
Does your dog have any awards or titles?
Has your dog had any hunting, herding, protection, attack or Schutzhund training?
Has your dog been trained as a therapy dog?
Have you ever used clicker training as a tool for training your dog?
What type of collar do you use?
□Flat□ Choker Chain□ Head Collar (Halti, Gentle Leader)
□ Harness□ Martingale□ Other
Does your dog know any tricks?
What is your dog's response to the following cues?
Please indicate: Good (G) Fair (F)Poor (P)
SitDown
Stay Heel
Come Fetch
PRESENTING PROBLEM
Please describe the behaviour problem in detail.
How long ago did the problem begin?
How often does the behaviour occur?
Has the problem changed over time in frequency and intensity? If so, how quickly has the change occurred?
When did the problem become serious? And why do you think this is?
Can you identify any factors that may have triggered or coincided with the onset of the problem behaviour? If so, please describe.
Can you predict when a problem is likely to occur? If so, please describe.
Describe the last three episodes in which the behaviour problem occurred (please include where it occurred, time of day, who was present, any possible triggers etc.)
1)The most recent incident
Date:
2)Second last incident
Date:
3)Third last incident
Date:
4)What was the first incident
Date:
What has been tried to correct the problem? How successful have these measures been?
How do you discipline your dog in general?
What are your goals for treatment?
WHICH OF THESE STATEMENTS APPLY TO YOU?:
□ I am here only out of curiosity, the problem is not serious
□ I would like to change the problem, but it is not serious
□ The problem is serious and I would like to change it, but if it remains unchanged that isalright
□ The problem is very serious and I would like to change it, but if it remains unchanged I’llkeep my dog
□ The problem is very serious and I would like to change it. If it remains unchanged I will have my dog euthanased or will have to give him/her up
ADDITIONAL COMMENTS
Do you have any further information you feel may be relevant to this problem?
AGGRESSION SCREEN
**PLEASE SKIP THIS SECTION IF AGGRESSION IS NOT A PROBLEM**
Has your dog ever bitten another dog?□ Yes□ No
Has your dog ever bitten any other animals?□ Yes□ No
Has your dog ever bitten any adults?□ Yes□ No
Has your dog ever bitten any children?□ Yes□ No
Has your dog bitten and broken the skin?□ Yes□ No
How many bites have broken the skin?
How many times has your dog bitten (that did or did not break the skin)?
How many times has your dog shown aggression (growling, snapping, biting)?
Please describe a typical episode when your dog shows aggression (does the dog growl, lunge or bite, and in what circumstances?)
If your dog is placed in the above situation 10 times, how many of those times is aggression seen? (All = 100%, just once = 10%)
What part of the body has the dog bitten and how severe were the injuries?
Who is/are the target of the aggression?
Did your dog bite as a puppy?□ Yes□ No
If yes, please describe, including at what age
How old was your dog when he/she first barked at a person?
What was the circumstance?
How old was your dog when he/she first barked at another animal/dog?
What was the circumstance?
How old was your dog when he/she first growled at a person?
What was the circumstance?
How old was your dog when he/she first growled at another animal/dog?
What was the circumstance?
How old was your dog when he/she first snapped or bit at a person?
What was the circumstance?
How old was your dog when he/she first snapped or bit at another animal/dog?
What was the circumstance?
Which of the following are applicable to your dog when he/she is showing aggressive behaviour?:
Attacks seem sudden and surprising□ Yes□ No
Episodes appear unprovoked□ Yes□ No
The dog is abruptly docile after an episode□ Yes□ No
The dog appears ‘sorry’ afterwards□ Yes□ No
The dog appears disorientated afterwards□ Yes□ No
Episodes are associated with a ‘glazed’ or ‘absent’ look□ Yes□ No
I can usually tell when will set my dog off□ Yes□ No
The aggressive behaviour is new and uncharacteristic□ Yes□ No
Thank you for taking the time to thoroughly complete this form. It will aid us in forming a diagnosis and plan for your dog. We look forward to working with you.
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