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













Training

























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:


















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

























Handling
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: http://www.tfaforms.com/344713

Page 5

Departure Behavior Screening




















Reactivity
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

Miscellaneous
(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.