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*
Appointment Date
Appointment Time:
 : 
Client Address:
Client Email:
Cell Phone:
-
Home Phone:
-
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
Name of Veterinary Clinic
Vet's Address:
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?)
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?
What basic training has your dog had? (select all that apply)
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
Please list all animals in the household, including the dog you are bringing, in the order in which they were obtained.
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:
How many times a day or week do you walk your dog?
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)

GR=Growl SL=Snarl/Bare Teeth SB=Snap/Bite NR=No Reaction NA= Not Applicable
Which of these best describes you?

FOR AGGRESSION TOWARDS PEOPLE
(Skip this section if aggression is not the problem)

Please check yes or no to these characteristics of your dog's aggressive behavior
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?