Canine Behavior Consultation Questionnaire

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Page 1

General Information

Name

Address

Zipcode

Phone: Home

Phone: Cell

Fax

Date of behavior consultation

Your primary care veterinarian's name and clinic name

Clinic address

How did you hear about Behavior Solutions?

Pet Information

Pet's Name

Date of Birth

Weight

Sex

MaleFemale

Neutered

YesNo

Age Neutered

Any changes in behavior after neutering?

Breed

Color

Age obtained

Breeder (if applicable)

Describe previous home/homes (if known):

For what purpose was your pet obtained?

Behavior of pet's 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:

When is your pet fed?

How often is your pet fed?

Type of treat(s)?

How often do you give treats?

When do you give treats?

List any supplements.

List all other pets (include species, breed, age, and sex).

Describe how your pets get along with each other.

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

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

Page 2

Reinforcer Assessment

What is your dog's favorite reward?

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

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

Daily Activities and Routine

Type of exercise/play:

Who exercises/plays with your pet?

For how often/how long?

Favorite toy(s):

Favorite game(s):

Where is your dog's favored sleeping spot?

Where does your dog sleep at night?

Have you ever used a crate for confinement?

YesNo

If yes, describe crate and location

Describe your dog's reaction to being crated.

Do you still use a crate?

YesNo

If no, when and why did you stop?

Briefly describe the usual daily schedule for the family.

Training

Has this pet had obedience training?

ClassPrivate instructorI trained my pet at homeNo

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

Please indicate the type(s) of training collar used

None, trained off leashNeck collarRemote collarHead halterBody harness

Please describe your dog's response to off leash training.

Please rate the success of off leash training for your dog (Score 1-5; 1= poor, 5= good).

Please indicate the type of neck collar used.

Please describe your dog's response to a neck collar.

Please rate the success of a neck collar for your dog (Score 1-5; 1= poor, 5= good).

Please indicate the type of remote collar used (i.e., shock, citronella, etc.)

Please describe your dog's response to a remote collar.

Please rate the success of a remote collar for your dog (Score 1-5; 1= poor, 5= good).

Please indicate the type of head halter used.

Please describe your dog's response to a head halter.

Please rate the success of a head halter for your dog (Score 1-5; 1= poor, 5= good).

Please indicate the type of body harness used.

Please describe your dog's response to a body harness.

Please rate the success of a body harness for your dog (Score 1-5; 1= poor, 5= good).

How would you describe the training?

Reward-basedAssertive/domineeringAversive/mostly correctionsOther

Briefly describe the training techniques:

What training was most successful?

Describe your dog's learning ability.

Is there any ongoing training?

YesNo

If yes, describe:

List family member(s) with the most control:

List family member(s) with the least control:

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:

Sit

Sit-stay 1 minute

Sit-stay 5 minutes

Sit-stay 10 minutes

Down

Down-stay 1 minute

Down-stay 5 minutes

Down-stay 10 minutes

Comes (indoors)

Comes (in yard)

Comes (in park)

Heels- with distractions

Heels-with no distractions

Give/drop

Does your dog know any tricks?

YesNo

If yes, list/explain:

Can you get your dog to settle on command?

YesNo

If yes, describe:

Punishment

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

Physical punishment:

YesNo

Dog's reaction:

Noise punishment (shaker can/siren):

YesNo

Dog's reaction:

Ultrasonic:

YesNo

Dog's reaction:

Water sprayer:

YesNo

Dog's reaction:

Verbal reprimands:

YesNo

Dog's reaction:

Physical handling: muzzle grasp

YesNo

Dog's reaction:

Physical handling: pinning

YesNo

Dog's reaction:

Time-out

YesNo

Dog's reaction:

Booby traps/repellants

YesNo

Dog's reaction:

What punishment is most effective?

Does any punishment make the problem worse?

YesNo

If yes, describe:

Has punishment ever led to threatening behavior or aggression from your dog?

YesNo

If yes, explain:

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

YesNo

If yes, describe:

Handling

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

Nail trimming?

Ear cleaning?

Brushing?

Bathing?

Rubbing belly?

Patting head?

Being lifted?

Grabbing collar?

Rolling over?

Teeth brushing?

Giving pills?

Giving liquid medications?

Hugging/kissing?

Page 4

Housetraining screen

Where is your dog's primary location for fecal and urine elimination?

On average how many times per day does your dog urinate?

Defecate?

Is your dog completely housetrained?

YesNo

Do you accompany your dog to its elimination site?

YesNo

Does your dog ever eliminate outdoors?

YesNo

What's your dog's favored location outdoors?

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?

YesNo

If yes, describe:

About how often does your dog housesoil?

When is your dog most likely to housesoil?

Does your dog soil in the home by:

UrinatingDefecating Both

Where are the most likely locations for indoor elimination?

Does your dog housesoil when family members are at home?

YesNo

If yes, describe:

Does your dog housesoil when you are watching?

YesNo

If yes, describe:

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

Does your dog urine mark?

YesNo

If yes, describe:

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

YesNo

Does your dog ever leak/dribble urine?

YesNo

Do you ever confine your dog to a crate?

YesNo

If yes, does your dog ever eliminate in the crate?

YesNo

Uncontrollable urination when excited?

YesNo

Uncontrollable urination when frightened?

YesNo

Does urine leak while your dog is:

SleepingWalkingApproached by ownersApproached by a stranger

Medical Screen

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

Appetite

NormalVoraciousDecreasedPickyIncreasedEats fast

Does your pet have any arthritis or other painful conditions?

YesNo

If yes, describe:

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

YesNo

If yes, describe:

Does your pet drink or urinate excessively?

YesNo

If yes, describe:

Stools

NormalConstipationLess frequentMore frequentSoft/diarrhea

Urine:

NormalInfrequentMore frequentMore volume

Does your pet have normal eating and bowel movements?

YesNo

If no, describe:

Does your pet have any medical problems?

YesNo

If yes, describe:

Is your pet presently on any medication?

YesNo

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

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

YesNo

If yes, indicate any abnormal findings:

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

When you go out is your dog confined or crated?

YesNo

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 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?

YesNo

If yes, describe your dog's reaction:

Is the dog ever alone outdoors?

YesNo

How often?

How long (on 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?

YesNo

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?

YesNo

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: