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Home » Behavioral Consult Packet Form

Behavioral Consult Packet Form

Please submit this form at least 48 hours before your scheduled behavioral consultation appointment or call 907-488-2335 to reschedule.

Canine Behavior Consultation Questionnaire

General Information

Name

Date of Consultation

MM slash DD slash YYYY

Address

Street Address

City

State / Province / Region

ZIP / Postal Code

Email

Phone (Home)

Phone (Business)

Fax

For referred cases: Veterinarian's name & clinic

Clinic Phone

Clinic Address

How did you hear about our service?

Pet Information

Pet's Name

Date of birth

Weight

Sex

Male

Female

Neutered

Yes

No

Age Neutered

Any change after neutering?

Breed

Color

Age obtained

Where did you obtain this pet?

Breeder (If possible)

Describe previous home/homes (if known)

For what purpose was your pet obtained?

Behaviour of parents or littermates (if known)

Briefly describe your dog's personality (e.g quiet,confident, excitable, unruly, bold, stubborn, etc)

The Home Environment

Type of food

How often is your pet fed?

When fed?

Type of treat(s)?

When do you give treats?

How often do you give treats?

List any supplements

List all other pets, including species, breed, age, and sex

Describe how your pets get along with each other

List each family member living in the home (include sex and age of children)

Describe briefly how your pet gets along with each family member including any problems

Reinforcer Assesment

What is your dog's favorite reward?

If you could give your dog ANY food as a reward, what would be the favourite? List the top five

Other than food, what rewards (e.g., toy, affection) would be most enticing to your dog? List the top five

Daily Activities and Routine

Type of exercise/play

Who exercises/plays?

How often/how long?

Favorite game(s)

Favorite toy(s)

Where is your dog's favored sleeping spot?

Where does the dog sleep at night?

Have you ever used a crate for confinement? Y/N If yes, describe crate and location

Describe the dog's reaction to being crated?

Do you still use a crate?

Yes

No

If no, when and why did you stop?

Briefly describe the usual daily schedule for the family

Training

Has this pet had obedience training?

Yes

No

Where your pet trained?

Class

Private Instructor

I trained my pet at home

Describe training classes your dog has had (including trainer's name if applicable)

Type of Training: None, trained off leash

Yes

No

Indicate type

Dog's response

Success (rate 1-5; 1 = poor, 5 = good)

Type of Training: Neck collar

Yes

No

Indicate type

Dog's response

Success (rate 1-5; 1 = poor, 5 = good)

Type of Training: Remote collar

Yes

No

Indicate type (i.e., shock, citronella, etc.)

Dog's response

Success (rate 1-5; 1 = poor, 5 = good)

Type of Training: Head halter

Yes

No

Indicate type

Dog's response

Success (rate 1-5; 1 = poor, 5 = good)

Type of Training: Body harness

Yes

No

Indicate type

Dog's response

Success (rate 1-5; 1 = poor, 5 = good)

How would you describe the training?

Reward-based

Assertive/domineering

Aversive/mostly corrections

Other

Other method of training

Briefly describe the training techniques

What training was most successful?

What training was least successful?

Describe your dog's learning ability

Is there any ongoing training?

Yes

No

Describe

List family member(s) with most control

List family member(s) with most control

For each of the following use a scale of 1 (poor) to 5 (excellent) to indicate how your dog responds

Sit

Sit-stay 1 minute

Sit-stay 5 minutes

Sit-stay 10 minutes

Down

Down-stay 1 minute

Down-stay 5 minutes

Down-stay 1O minutes

Come

Come (indoors)

Come (in yard)

Come (in park)

Heel – with no distractions

Heel – with distractions

Give/drop

Does your dog know any tricks?

Yes

No

List / Explain

Can you get your dog to settle on command?

Yes

No

If yes, describe

Punishment

Have you ever used any of the following for punishment or training?

Physical punishment

Yes

No

Dog's reaction

Noise punishment (shaker can/siren)

Yes

No

Dog's reaction

Ultrasonic

Yes

No

Dog's reaction

Water sprayer

Yes

No

Dog's reaction

Verbal reprimands

Yes

No

Dog's reaction

Physical handling: Muzzle grasp

Yes

No

Dog's reaction

Physical handling: Pinning

Yes

No

Dog's reaction

Time-out

Yes

No

Dog's reaction

Booby traps/repellants

Yes

No

Dog's reaction

What punishment is most effective?

Does any punishment make the problem worse?

Yes

No

If yes, describe

Has punishment ever led to threatening behavior or aggression?

Yes

No

Explain

Does your dog respond differently to punishment from different family members?

Yes

No

Explain

Handling

How does the dog react to the following types of handling

Nail trimming?

Ear cleaning?

Brushing?

Bathing?

Rubbing belly?

Patting head?

Grabbing collar?

Being lifted?

Rolling over?

Teeth brushing?

Giving pills?

Giving liquid medications?

Hugging/kissing?

Housetraining Screen

Where is your dog's primary location for elimination?

On average, how many times a day does your dog

a) urinate

b) defecate

Is your dog completely housetrained?

Yes

No

Does your dog ever eliminate outdoors?

Yes

No

Do you accompany your dog to its elimination site?

Yes

No

What is your dog's favored location outdoors?

What is your preferred location for your dog to eliminate?

What do you do after your dog eliminates in the correct location?

What do you do when you catch your dog soiling in an incorrect location?

Does your dog signal to eliminate?

Yes

No

If yes, describe:

About how often does your dog housesoil?

When is the dog most likely to housesoil?

Does your dog soil in the home by urinating, defecating indoors or both? (circle one)

What are the most likely locations for indoor elimination?

Does your dog housesoil when family members are at home?

Yes

No

If yes, describe:

Does your dog housesoil while you are watching?

Yes

No

If yes, describe:

What do you do when you find urine or stool in the improper location?

Does your dog urine mark?

Yes

No

If yes, describe:

Does your dog ever eliminate in a location where he/she has been sleeping?

Yes

No

Does your dog ever leak/dribble urine?

Yes

No

Do you ever confine your dog to a crate?

Yes

No

Does your dog ever eliminate in the crate?

Yes

No

Uncontrollable urination when excited?

Yes

No

Uncontrollable urination when frightened?

Yes

No

Does urine leak while your dog is

a) sleeping?

b) walking?

c) approached by owners?

d) approached by stranger?

MEDICAL SCREEN

Appetite:

Normal

Voracious

Decreased

Picky

Increased

Eats fast

Does your pet have any arthritis or other painful conditions?

Yes

No

If yes, describe:

Have you noticed any deficits in your pet's senses?

Yes

No

If yes, describe:

Does your pet drink or urinate excessively?

Yes

No

If yes, describe:

Stools:

Normal

Constipation

Less frequent

More frequent

Soft/diarrhea

Urine:

Normal

Infrequent

More frequent

More volume

Does your pet have normal eating and bowel movements?

Yes

No

If no, describe:

Does your pet have any other medical problems?

Yes

No

If yes, describe:

Is your pet presently on any medication?

Yes

No

If yes, describe (include name, dosage, duration):

Has your pet had any laboratory tests (blood, urine, X-rays, etc.)?

Yes

No

If yes, indicate any abnormal findings:

DEPARTURE BEHAVIOR SCREENING

When you go out is your dog confined or crated?

Yes

No

If yes, indicate if crated or what areas are restricted:

How long is the dog left alone on the average day?

At what time of the day is your dog left alone?

How does your dog react when you prepare to leave?

Has your dog ever been left at a kennel, veterinary office, or with a friend/relative?

Yes

No

If yes, describe your dog’s reaction:

Is the dog ever alone outdoors?

Yes

No

How often?

How long (average)?

Where is the dog left when outdoors?

How does your dog react to being left alone outdoors?

Does your dog exhibit any behavior problems when you leave it alone?

Yes

No

If No, proceed to Reactivity below

Describe your dog’s behavior when left alone at home (list problems and how long after departure they occur)

Does the behavior differ depending on length of time or time of day left alone?

How does your dog react at the time of departure (as the last person prepares to leave)?

Does the behavior differ depending on who is the last to leave?

What is the dog’s reaction at homecomings?

Have you ever left the dog alone in the car?

Yes

No

If yes, how does it react?

REACTIVITY – indicate how your dog reacts to each of the following (check all that apply)

Familiar dogs on property:

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

Familiar dogs off property:

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

New dogs on property

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

New dogs off property:

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

Strangers outside on property:

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

Strangers off property

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

Strangers arriving indoors:

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

Car rides:

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

Thunderstorms/fireworks:

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

Other loud noises (e.g., shouting):

Calm

Excited

Ambivalent

Fearful

Friendly

Aggressive

AGGRESSION SCREEN

Has your pet ever displayed any:

Threatening displays?

Yes

No

Growling?

Yes

No

Bites?

Yes

No

Bite attempts?

Yes

No

When was the most recent attempt to bite or threaten?

Has this problem entirely resolved?

Yes

No

Situations causing aggression:

Petting/handling/restraint:

growled

attempted to bite

bitten

no aggression

If yes, describe:

Eating food or treats:

growled

attempted to bite

bitten

no aggression

If yes, describe:

If new people approach:

growled

attempted to bite

bitten

no aggression

If yes, describe:

Chewing toys/stolen objects:

growled

attempted to bite

bitten

no aggression

If yes, describe:

Waking up:

growled

attempted to bite

bitten

no aggression

If yes, describe:

If there have been no signs of aggression (growl, bite attempts, biting) or if it has been entirely resolved, then proceed to next page.

Is aggression the primary reason for today’s visit?

Yes

No

What is the potential for injury:

a) none/preventable

b) minimal

c) moderate

d) severe

Is the problem serious enough that you will be unable to keep your pet if it is not improved?

Yes

No

Is your dog ever aggressive to members of the immediate family?

Yes

No

If yes, who? Describe:

Is your dog ever aggressive to visitors to your home?

Yes

No

Were the people known, strangers, or both? (circle one) Describe:

Is your dog aggressive to people when off property?

Yes

No

Were the people known, strangers, or both? (circle one) Describe:

Is there a particular person or type (age, sex, uniforms) that your dog is most likely to threaten or bite?

Is there a particular person or type (age, sex, uniforms) that your dog is most likely to threaten or bite?

Has your dog ever bitten hard enough to break skin or cause injury?

Yes

No

If yes, describe:

Describe situations where your dog barks, threatens, or growls, but does not bite:

Does your dog ever display aggression to other animals?

Yes

No

If yes, what animals? Describe aggression:

When your dog threatens or attempts to bite, how do you handle the situation and what is the dog’s reaction?

After your dog has bitten, how do you handle the situation and what is the dog’s reaction?

How would you describe your dog’s attitude at the time of the aggression? (bold, protective, outgoing, fearful, etc.)

How would you describe your dog’s expression and postures at the time of aggression? (cowering, ears back, tail tucked, hackles raised, retreating, hiding)

PRINCIPAL COMPLAINT

What is the primary problem? (aggressive, destructive, house soiling, barking, etc.):

How would you describe the severity of this problem? (circle one) Mild Moderate Severe

Have you considered euthanasia?

Yes

No

If yes,Comment:

Please answer all of the following unless they have been entirely covered in another section:

When did the problem begin?

What age was your pet when this problem started?

What do you think caused the problem?

Describe the problem, beginning with the most recent incident

Describe previous incidents:

Describe the first incident:

How often does the problem occur?

Has there been a recent change in frequency or severity?

Yes

No

If yes, describe:

Describe any changes in the home or the pet’s health when the problem first started:

What has been done so far to try and correct the problem?

What has been the dog’s response?

List any techniques that have been at all successful:

List any techniques that have made the problem worse:

List any drugs (include dosage) tried so far, and the dog’s response to medication:

List any other dietary treatments, supplements, or remedies and the dog’s response:

MISCELLANEOUS (please answer any of the following that have not been previously discussed)

Disobedient:

Jumps up (owners)

Yes

No

Jumps up (strangers)

Yes

No

Won't come when called

Yes

No

Nips/grabs with mouth

Yes

No

Only listens when feels like it

Yes

No

Pushy/demanding

Yes

No

On furniture where not allowed

Yes

No

In rooms where not permitted

Yes

No

Exploratory:

Normal

Infrequent

Increased

Excessive

Activity:

Normal

Lazy/inactive

Restless/won’t settle

Highly active

Overactive

Sleep:

Normal

Increased

Less frequent

Restless sleep

Night waking

Stool eating:

Yes

No

Untitled

own stools

other dogs

cats

other

Garbage raiding:

Yes

No

Food stealing:

Yes

No

Eats non-food items (pica)

Yes

No

Licks objects

Yes

No

If yes to any of above, describe

Destructive:

Chewing

Yes

No

Digging

Yes

No

Others

If yes, describe:

Grooming:

Normal grooming

Yes

No

Excessive grooming/licking

Yes

No

Self-injurious

Yes

No

If there is abnormal grooming, describe:

Repetitive/compulsive/unusual activity:

Tail chasing

Sucking

Star gazing

Fly chasing

Light chasing

Staring

Other

If yes to any of above, describe:

Chasing:

Yes

No

If yes, describe:

Hunting/predation:

Yes

No

If yes, describe:

Sexual habits:

Masturbation

Yes

No

Mounting

Yes

No

Roaming/running away

Yes

No

Describe any undesirable sexual habits:

Vocalization:

Barking

Yes

No

Whining

Yes

No

Howling

Yes

No

If yes, describe:

Anxiety/fear:

Noise sensitivity

Yes

No

If yes, describe:

Phobic/excessive fear/panic:

Yes

No

If yes, describe:

Shyness/timidity (non-aggressive): e.g., ears back, cowering, tail tucked, shaking, retreating, hiding, etc

Yes

No

If yes, describe any situations not discussed previously where your dog is fearful or overly anxious:

How long after exposure to these events is finished does your dog settle down (i.e., back to normal)?

Additional problems or comments:

VETERINARY HISTORY FORM (for referred cases, to be completed by referring DVM prior to consultation

Clinic

Phone

Doctor’s name:

Fax #:

Client’s name:

Pet’s name:

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Behavioral History

Describe the pet’s behavior in your clinic, including any problems that you have observed:

For what behavior problem is this dog being referred? (i.e., presenting complaint or diagnosis)

Please indicate any advice or counseling that you have given the client thus far (including dates):

Have any medications or products been suggested? If yes, indicate dates, duration, and response:

Medical History

Date of most recent physical/dental examination:

MM slash DD slash YYYY

List any abnormal findings:

Vaccination status:

Vaccines administered:

List any present medical problems:

Are you aware of any sensory deficits?

Yes

No

If yes, describe:

Are you aware of any painful conditions in this pet?

Yes

No

If yes, describe:

List any recurrent or previous medical problems:

Is the pet presently receiving treatment or medication of any type?

Yes

No

If yes, describe:

Diagnostic Screening Tests

Attach a copy of all recent diagnostic or screening tests. Alternatively, please complete this section.

Indicate what diagnostic or screening tests have been performed and the date of each:

List any abnormal results

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2942 Hurst Road,
North Pole, AK 99705

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Monday

GP: 8am - 6pm | Emerg: 6pm - 12am

Tuesday

GP: 8am - 6pm | Emerg: 6pm - 12am

Wednesday

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Thursday

GP: 8am - 6pm | Emerg: 6pm - 12am

Friday

GP: 8am - 6pm

Saturday

GP & Emerg: 9am - 5pm

Sunday

Closed

GP = General Practice | Emerg = Emergency. For daytime emergencies, please contact your regular veterinary hospital immediately.

North Pole Veterinary Hospital

(907) 488-2335

2942 Hurst Road,
North Pole, AK 99705

Request an Appointment

About Us
Services
Emergencies & After Hour Care
Online Pharmacy
Client Corner
Contact Us
Payment Options
Careers

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