When Completed, Return by Email To

Behavior Questionnaire

WHEN COMPLETED, RETURN BY EMAIL TO

Call 314-832-3647 if you have questions

If you are completing this form electronically, use the tab key to move to each new field. Use the space bar to check a box.

HOUSEHOLD INFORMATION

Owner / Handler Name: Date:

Email (Please ensure we have a valid email address. We send most of our correspondence by email.):

Best Phone: Alternate phone:

Dog’s name:Breed: Age:

Sex:Altered? Yes No Age at surgery:

How were you referred to this service?

My veterinarian

A staff member of the Human Society of Missouri recommended it

A friend or family member

I found it on the Shrewsbury City Center website

I found it doing a web search

Other (please specify):

List the members of your household and their ages, including yourself:

Your occupation:

What other pets do you have, other than the dog you wish to bring to class?

SPECIFIC BEHAVIOR PROBLEM AND HISTORY

At what age did you get your dog?

Under 16 weeks (4 months)

Between 4 and 6 months

Between 6 months and 2 years

Over 2 years

How did you acquire the dog?

Rescue group (dog was in foster home prior to acquiring)

Shelter or rescue facility

Breeder

Friend or family member

Other (please specify):

What information do you know about your dog’s socialization to other dogs, children, strangers/people, cats, other animals?

What is the main behavior problem or complaint?(Choose only 1 answer for this question. You will be able to tell us about other concerns in the next question.)

Aggressive behavior toward unfamiliar dogs
Aggressive behavior toward familiar, household dogs
Aggressive behavior toward unfamiliar people
Aggressive behavior toward familiar people, people in the home
Fearful behavior around unfamiliar dogs
Fearful behavior around unfamiliar people
Fear of noises
Fear of locations
Fear of specific objects
Other (please specify):

Please describe several examples of the main behavior problem in detail:

Description / Date
1. Most recent incident
2. Second to last incident
3. Third to last incident

For the most recent incident, please describe how you responded?

When did you first notice the main problem (age of dog)?

When did it first become a serious concern?

Has the main problem you identified changed in frequency? (For example, did it occur only monthly and now is occurring weekly. Please describe)

Has the main problem you identified changed in intensity? (For example, the response was fairly mild in the past and is now more intense. Please describe)

Please identify any additionalbehavior problems you are having with your dog.

Other (please specify):

How frequently does the problem (or problems) occur:

Daily / Weekly / Monthly / A few times a year
Aggressive behavior toward unfamiliar dogs
Aggressive behavior toward familiar, household dogs
Aggressive behavior toward unfamiliar people
Aggressive behavior toward familiar people, people in the home
Fearful behavior around unfamiliar dogs
Fearful behavior around unfamiliar people
Fear of noises
Fear of locations
Fear of specific objects
Other (please specify):

Has your dog ever bitten, regardless of the circumstances? Yes No

Describe the result of the bite:

Snap with jaws, no contact with skin.

Single bite and release; bruises only.

Single bite and release; shallow puncture wounds; light bruising

Single bite and release; deep puncture wounds; deep bruising

Multiple bites. Dog hung on, shaking the limb or other dog.

Number of bites that broke skin:

Total number of bites (that did or did not break skin):

Total number of episodes of aggression (growling, snapping, biting):

In an unfamiliar room, is your dog likely to be too fearful to move? Yes No

In a new situation, will your dog take treats? Yes No

DAILY ROUTINES

Food

When and where is your dog fed? (how often and at what time):

What happens if your dog does not finish all the food?

Who feeds your dog:

Describe any activity your dog does prior to getting fed? (such as sitting, waiting or tricks):

How often does your dog get treats in a typical day?

Describe any activity your dog does prior to getting treats? (none, just cute; sitting, waiting)

Sleeping

Where does your dog sleep?

If your dog sleeps on the bed, is s/he invited into the bed?

Does your dog wake you up in the morning?

Going outside

When does your dog go outside for a potty break and for how long?

How does your dog ask to go outside?

Exercise and Playtime

When does your dog go outside for play or exercise and for how long?

What type of exercise does your dog receive (e.g., walking on leash, walking/running off leash)?

What type of playtime does your dog get regularly (e.g, fetch, tug, tricks)?

Who initiates play sessions, you or your dog?

Are toys (other than chew items) always available for your dog?

MEDICAL INFORMATION

Date of last veterinary visit and reason for visit:

Has your dog been under veterinary care for the behavior problem you identified? Yes No

If so, what was the veterinarian recommendation, were you able to follow the recommendation and what was the result?

Is your dog on any medication now, for this or other problems?

Has your dog been on medication in the past?

PREVIOUS TRAINING EXPERIENCE

Has your dog attended Puppy, or Obedience classes? Yes No

If so, how did your dog participate?

What kind of equipment have you usedwith your dog?

Currently using / Used in the past
4-6 foot leash
Retractable leash
Flat collar (buckle or clip)
Martingale or limited slip collar
Slip, chain or choke collar
Prong collar
Electronic collar
Head halter
Body harness that clips between shoulders
Body harness that clips in front of chest
Invisible electronic fence
Mesh or nylon muzzle
Basket muzzle

GOALS AND FINAL COMMENTS

What are your short term goals?

What are your long term goals?

Please provide any other information you believe is important to help understand your dog’s behavior and/or previous training (use additional pages if needed):