Dog Behavior History Form - Peak Veterinary Referral Center

1Veterinary Behavior Consultation ServiceLisa Nelson, VMDThank you for making an appointment for a behavior consult for your pet! Please read the informationbelow and keep this page for your records. Please do not return this page with your history form.History Form:• Please take your time in filling out the questionnaire. The more details you can provide in the questionnaire, the lesstime we will need to make sure the history is complete at the consult. The firms are somewhat long, but theinformation requested is very important.• Please be sure to fill out the questionnaire on the printed side only. If you need to add more information which youthink might be helpful, include extra pages. It is advisable for you to make a copy of the completed questionnaire foryour records.• A video of behaviors that are of concern is always helpful, but only if the safety of people or other animals involved isthe number one priority.Behavior Consult• Please plan on spending approximately 2-2.5 hours at this consult. All immediate family members are encouraged toattend.• If your dog already uses training aids (i.e. clickers, treats, treat bags, collars, harness, headcollars, muzzle) pleasebring them with you, even if they have not been helpful so far! Your leash should be 4’-6’ long andnylon/leather/canvas (not a chain leash).• We will be using food rewards at the consult. Please do not feed your pet before the consult and bring along her/hisfavorite small treats, especially if your pet has food/ingredient restrictions. Treats that are available at the consult aretypically lamb-based food for dogs and fish based food for cats.• You are welcome to bring your pet’s favorite towel or blanket for her/him to lie on during the consult; we are happyto provide one if that is easier for you.• Cats must be in carriers or on a harness to come in for a behavior consult.• Your pet’s behavior and interactions with you may be video recorded during the consult.• During the consult we will work on clarifying any parts of the questionnaire that warrant further explanation, which iswhy the information you provide in the history form is so important. We will also spend time discussing diagnoses—without a diagnosis it is very difficult to develop a treatment plan.• The treatment plan may consist of a combination of behavior modification, environmental management strategies andpharmacological therapy. At the time of the consult you will be provided with a written treatment plan and handouts;an expanded treatment plan and additional handouts may also be developed after the appointment and sent to you.Your veterinarian will receive a copy of the treatment plan, including information about recommended or prescribeddrug therapy.After the consult:• Please read all the information that is provided to you, and have all family members become familiar with the plan.• Telephone and email check-ins are an important part of follow-up care for your pet, especially if drug therapy hasbeen prescribed. At the time of the consult, we will set up a check-in schedule so that we can assess areas of progressand areas that need further help. Your consult fee includes a 3-month period for follow-up by phone and/or email.• Behavior problems that are complex or that are long standing may benefit from a recheck or second consult. Recheckappointments are typically 1 hour long and are done at Peak Veterinary Referral Center or by house call, dependingon the nature of the problem. These recheck appointments are designed to assess progress and work on specificbehavior modification protocols.• If drug therapy is part of the recommended treatment plan, your pet will need to be rechecked by Dr. Nelson at 6-month intervals.PEAK VETERINARY REFERRAL CENTER 158 Hurricane Lane, Williston, VT 05495| p: 802-­‐878-­‐2022 | f: 802-­‐878-­‐1524 www.peakveterinaryreferral.com

6How often does this second other problem behaviors occur relative to the situation? < 25% of time 26%-50% of time 51%-75% of time 76%-100% of time3. Do situations in which the third other problem behavior occurs happen daily weekly randomly rarely?How often does this third other problem behavior occurs relative to the situation? < 25% of time 26%-50% of time 51%-75% of time 76%-100% of timeGeneral Behavior Information:Does your dog mount people [ ], other animals [ ] or objects [ ]? yesPlease describe situation when this occurs: noDoes your dog ever bark at you? yes noWhen? Please describe:Does your dog bark at other times? yesPlease describe: noDoes your dog jump up on you [ ] or others [ ] without permission? yes noIf yes, when?:Does your dog paw at you[ ] or at others[ ]? yesIf yes, when?: noPlease check any other problems not mentioned above and briefly describe: housesoiling—see below destructive chewing—see below behavior in crate— vocalizes salivates scratches at door urinates in crate, defecates in crate destroys blankets tries to escape escapes excess grooming/licking digging in yard swallowing non-food items (describe) eating stool ---- her/his own other household animals wild animals pacing spinning/tail chasing unruliness running awayPEAK VETERINARY REFERRAL CENTER 158 Hurricane Lane, Williston, VT 05495| p: 802-­‐878-­‐2022 | f: 802-­‐878-­‐1524 www.peakveterinaryreferral.com

8Please place check marks that best describe your dog’sbehavior in each of the following situations. Please notethat family member only refers to family living in the homewith the dog. Familiar visitor refers to a person the dogsees routinely in the home but who does not live there.Unfamiliar person could be a delivery person/completestranger/first time visitorAppearscomfortableMovesAwaySnarlLipCurlBarkGrowlSnapBiteNotDone1. family member pets dog2. family member hugs dog3. family member picks up dog4. family member reaches toward dog5. family member reaches over dog’s head6. family member takes away rawhide/bone/chew toy7. family member takes away “stolen” item8. family member approaches dog while eating9. family member takes food away while dog eating10. family member reaches for food dropped on floor11. family member disturbs dog while sleeping12. family member pushes dog off bed/couch13. family member puts on leash14. family member puts on collar/training collar15. family member clips nails16. family member bathes dog17. family member grooms dog18. family member pushes dog over onto back19. family members play with dog and dog’s toy20. family members play together but not with dog21. family member approaches dog next to family member22. family member calls dog over to herself/himself23. family member comes in door24. unfamiliar person at door25. unfamiliar person is in the home26. unfamiliar person approaches dog next to familymember27. unfamiliar person reaches toward dog/tries to pat28. unfamiliar person calls dog over to herself/himself29. unfamiliar person reaches over dog’s head30. unfamiliar person approaches car with dog insidealone31. familiar visitor comes in door32. familiar visitor is in home 33. familiar visitor approaches dog next to family member34. familiar visitor reaches toward dog/tries to pat36. familiar visitor calls dog over to herself/himself37. familiar visitor reaches over dog’s head38. dog on leash approached by unfamiliar person39. dog off leash approached by unfamiliar person40. dog on leash approached by another dogPEAK VETERINARY REFERRAL CENTER 158 Hurricane Lane, Williston, VT 05495| p: 802-­‐878-­‐2022 | f: 802-­‐878-­‐1524 www.peakveterinaryreferral.com

10Were there any behavior changes after neutering? yes no do not knowIf yes, please explain:If your pet is intact, has he/she ever been bred? yes noAre you planning to breed your dog? yes no unsureIf you have an intact female, when was her last heat?Home EnvironmentPlease list the people, including yourself, living in your household:Name Age Hours Away from HomePlease list all animals in the household including patient:Name Species Breed Sex Age Obtained Age NowIn what sequence were the above animals obtained? (Please number animals in the table above.)What is your dog’s relationship to the other animals in the house (e.g. mostly friendly, mostly aggressive, mostly fearful)?Please describe:When unsupervised or alone , are your animals separated from each other (i.e. by gate, crates, in different areas of house?) yes noIf so, please explain.Do your animals eat in same room at same time? yes noIf No, please explain.Do your dogs bark, growl, fight over valuable toys? yes noIf yes, please explain.PEAK VETERINARY REFERRAL CENTER 158 Hurricane Lane, Williston, VT 05495| p: 802-­‐878-­‐2022 | f: 802-­‐878-­‐1524 www.peakveterinaryreferral.com

13Where does your dog sleep during the day (be specific):Where is your dog when you have guests?Please describe a typical 24-hour day in your dog’s life, starting with when you wake up.(please be thorough and leave nothing out—include a separate page if necessary)Obedience TrainingWhat obedience training has your dog had? (check one) None Trained at home Started obedience classes but didn’t finish Graduated obedience class once Graduated obedience class more than once Private trainer Other ________________________How did your dog behave in obedience classes?Who in the family is the primary trainer?What commands does your dog know and how well? Sit Perfect Usually OK Needs work Stay Perfect Usually OK Needs work Lie down Perfect Usually OK Needs work Come Perfect Usually OK Needs work Wait Perfect Usually OK Needs work Heel Perfect Usually OK Needs work Fetch Perfect Usually OK Needs work Drop It Perfect Usually OK Needs work Other ___________________________________PEAK VETERINARY REFERRAL CENTER 158 Hurricane Lane, Williston, VT 05495| p: 802-­‐878-­‐2022 | f: 802-­‐878-­‐1524 www.peakveterinaryreferral.com