Canine Behavior Consultation Questionnaire

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Page 1

General Information

Pet Information

The Home Environment

Page 2

Reinforcer Assessment

Daily Activities and Routine


Page 3

Training continued
For each of the following commands, use a scale of 1 (poor) to 5 (excellent) to indicate how well your dog responds:

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

How does the dog react to the following types of handling?

Page 4

Housetraining screen

Medical Screen
***Please have your veterinarian send the last year of your pet's medical records to Dr. Sinn**

If this is a referred case, please have your veterinarian complete the medical portion of this questionnaire:

Page 5

Departure Behavior Screening

Indicate how your dog reacts to each of the following (check all that apply)

Page 6

Aggression Screen
Has your pet ever displayed any:

Page 7

Principal complaint

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

Page 8

(Please answer any of the following that have not previously discussed)

Page 9

Survey based on material from:
Landsberg G., Hunthausen W., Ackerman L. 2003. Handbook of Behavior Problems of the Dog and Cat. Sanders, Edinbergh.
(c) 2003, Elsevier Science Limited. All rights reserved.