Behavioral History Form

Pat Miller, CBCC-KA, CPDT-KA
17816 Spielman Rd.
Fairplay, MD 21733
info@peaceablepaws.com
www.peaceablepaws.com
301-582-9420

Please answer the following questions and submit the completed form.

Specific questions about the problem behavior(s) will be asked during your visit.

Please bring your dog’s medical records with you.

Payment methods accepted: Cash, check or credit card (Visa, Mastercard, Discover, American Express) in person, or PayPal at the website.

Cancellation policy: Appointments cancelled less than 48 hours in advance will be charged a $50 rescheduling fee. Appointments cancelled 48 hours or more in advance may be rescheduled without penalty. No penalty for appointments rescheduled due to inclement weather.

You are welcome and encouraged to take notes, and to audiotape or videotape your session.

Please note: We are a teaching facility as well as a training center. Peaceable Paws staff and/or apprentices may sit in on your session.

Submission of this behavioral history form constitutes permission to share your information with a consulting veterinarian.

Behavioral History Form

Client Name*

First

Last

Appointment Date

Appointment Time:

AM/PM

Client Address:

Street Address Street Address Line 2 City State Postal / Zip Code

Home Phone

Cell Phone

Client Email

Dog's Name

Breed

Age

Sex

Spayed/Neutered?

Age at Spay/Neuter

Where did you hear about Peaceable Paws?

Please be specific/include name when possible

Veterinarian's Name

First

Last

Name of Veterinary Clinic

Vet's Address:

Street Address Street Address Line 2 City State Postal / Zip Code

Vet's Phone

What brand and type of food does your dog eat?

Amount of food given per feeding

How often?

Who is the primary feeder?

Was this food prescribed/recommended by your vet?

Has your dog's appetite...

Does your dog sleep...

Does your dog (now or in the past ) have any medical conditions or health issues?

If Yes, please describe:

Is your dog on any medication now?

Medication #1 and Reason:

Medication #2 and Reason:

Medication #3 and Reason:

What is the main behavior problem or complaint?

Additional Problem #1:

Additional Problem #2

Additional Problem #3:

How Frequently does the problem (or problems) occur? (How many times a day/week/month?)

Day

Week

Month

Main Problem

Additional Problem 1

Additional Problem 2

Additional Problem 3

At what age did you first notice the main problem?

At what age did it first become a serious concern?

In what general circumstances does the dog misbehave?

Has the problem changed in frequency?

Please Describe:

Has the problem changed in intensity?

Please Describe.

Please describe several examples in detail

Date of most recent incident

Description of most recent incident

Date of second to last incident

Describe second to last incident

Date of third to last incident

Describe third to last incident

Other significant incidents:

What have you done so far to correct the problem?

How do you discipline your dog for this and other misbehaviors (if you do)?

Is your dog housetrained?

Does he/she have accidents?

If so, how many?

Single Choice:

per day

per week

per month

What methods were used in training? (i.e., choke chains, clicker/treats) – Please be specific

How old was the dog when training started?

If ended, at what age?

Please list all the people, including yourself, living in your household

Name

Age (of Children)

Hours away from home

Please list all animals in the household in the order in which they were obtained.
Please INCLUDE the dog(s) you are bringing to the consultation.

Animals in the household. Please include the dog, you are bringing, in the list.

Name

Species

Breed

Sex

Age Obtained

Age Now

Describe your dog's relationship to the other animals

Have you moved since acquiring your dog?

How many times?

Has your household (people or animals) changed since acquiring your dog?

Please Describe-

Does your dog run free in a fenced yard?

Is the dog tied outside?

Does the dog run free if you don't have a fenced yard?

Where?

How often:

Choice

per day

per week

How many times a day or week do you walk your dog?

choose

per day

per week

How long is each walk?

Why did you decide to get a dog?

Why did you choose this breed?

Where did you get this dog? (be as specific as possible – name of shelter/rescue/breeder, etc.)

Do you have any news about littermate behavior?

If yes, please describe-

If known, please describe the parents' behavior

Why did you choose this dog over the others?

Has this dog had other owners?

If yes, how many?

If so, why was the dog given up?

How does the dog behave with visitors? (children or adults, familiar or unfamiliar)

Are there certain types of people your dog seems to like better than others?

If Yes, please describe

How do you play with your dog?

What toys does the dog have, and how does he play with them?

Where is your dog when alone in the house?

Where is your dog when you have guests?

How does your dog behave when you are leaving the house?

What is your dog's activity level in general?

AGGRESSION SCREEN (Please check all that apply)
Please fill out this section even if aggression is not your dog's behavioral issue

Which of these best describes you?

FOR AGGRESSION TOWARDS PEOPLE
You do not need to answer the following questions on aggression if aggression is not your dog's behavioral issue

Has your dog bitten?

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

Total number of bites

Number of bites that caused bruising

Number of bites that broke skin

Number of bites that required a trip to the doctor/stitches

Describe typical episode (i.e., does dog growl, lunge, or bite, and in what circumstance?)

If in the above situation 10 times, how many times is aggression seen?

What parts of the body has the dog bitten?

Who are the targets of aggression?

How old was your dog the first time he/she growled at a person?

Describe

How old was your dog the first time he/she snapped or bit at a person?

Please describe

Anything else you would like to tell us?

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Fostering Harmony Between the Human and Non-Human Animals of Our World

Behavioral History Form