X/TwitterThis field is for validation purposes and should be left unchanged.Name* First Last Pet’s Name*Today’s Date* MM slash DD slash YYYY How did you hear of Abbey Animal Hospital?*Breed*Birth date*Age obtained*Sex* M F Pregnant?* Yes No Spayed/Neutered?* Yes No If yes, at what age:Weight*Where did you obtain this pet:* Breeder Friend Pet Store Humane Shelter Rescue Behavior Problems of parents or littermates, if known*Your primary veterinarian’s name:Name of Clinic or HospitalPhonePrincipal Behavioral ComplaintSummarize the primary behavior problem in one sentence:*How would you describe the severity of this problem?* Mild Moderate Severe Have you considered euthanasia?* Yes No o Please Comment:Describe the last two incidents in as much detail as possible. Include an approximate date of each incident:*FREQUENCYPlease indicate the number of times the problem has occurred in each of the times indicated below: PAST WEEK*PAST MONTH*PAST YEAR*Since you’ve owned*BACKGROUND INFORMATIONAt what age was your pet when the problem began?*Were there any changes in the home at that time?*List techniques you have used to correct the problem*TECHNIQUESWhat techniques (if any) have helped?*What techniques have made the problem worse?*Have any drugs been tried for this problem? If yes, what?*What do you think is the reason for your dog’s problem?*PERONS LIVING IN THE HOUSEHOLDList each person living in the household, including age, sex, time away from home (example 9am-5pm), and comments on that person’s relationship with your pet (for exam: “feeds dog” or “is afraid of dog”)*PETS LIVING IN THE HOUSEHOLDList all other pets in the household. Comment on the relationship between the dog with the behavior problem and your other pets (for example: “get along” or “dominates dog.”)*DIETBrand Name (WET DOG FOOD )How Often Given (WET DOG FOOD )Desire For This Type Of Food (WET DOG FOOD) Mild Moderate Strong Brand Name (DRY DOG FOOD )How Often Given (DRY DOG FOOD )Desire For This Type Of Food (DRY DOG FOOD) Mild Moderate Strong Brand Name (ADDITIONAL DOG FOOD )How Often Given (ADDITIONAL DOG FOOD )Desire For This Type Of Food (ADDITIONAL DOG FOOD) Mild Moderate Strong Brand Name (TABLE SCRAPS / PEOPLE FOOD )How Often Given (TABLE SCRAPS / PEOPLE FOOD )Desire For This Type Of Food (TABLE SCRAPS / PEOPLE FOOD ) Mild Moderate Strong Brand Name (TREATS TYPE 1 )How Often Given (TREATS TYPE 1 )Desire For This Type Of Food (TREATS TYPE 1 ) Mild Moderate Strong Brand Name (TREATS TYPE 2 )How Often Given (TREATS TYPE 2 )Desire For This Type Of Food (TREATS TYPE 2 ) Mild Moderate Strong Brand Name (SUPPLEMENTS / VITAMINS )How Often Given (SUPPLEMENTS / VITAMINS )Desire For This Type Of Food (SUPPLEMENTS / VITAMINS ) Mild Moderate Strong LOCATION/ACTIVITY/EXERCISEAMOUNT OF TIME per DAY or PER WEEK DOG SPENDS at this Site/Activity (In HOUSE, PER DAY )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (In HOUSE, PER DAY )INDICATE WHAT DOG WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (In HOUSE, per day)AMOUNT OF TIME per DAY or PER WEEK DOG SPENDS at this Site/Activity (In YARD, per day)INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (In YARD, per day)INDICATE WHAT DOG WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (In YARD, per day)AMOUNT OF TIME per DAY or PER WEEK DOG SPENDS at this Site/Activity (On WALK, per day)INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (On WALK, per day)INDICATE WHAT DOG WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (On WALK, per day)AMOUNT OF TIME per DAY or PER WEEK DOG SPENDS at this Site/Activity (PLAYTIME, per day )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (PLAYTIME, per day )INDICATE WHAT DOG WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (PLAYTIME, per day )AMOUNT OF TIME per DAY or PER WEEK DOG SPENDS at this Site/Activity (Jogging or structured exercise, per week )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (Jogging or structured exercise, per week )INDICATE WHAT DOG WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (Jogging or structured exercise, per week )AMOUNT OF TIME per DAY or PER WEEK DOG SPENDS at this Site/Activity (Off lease (free), per week )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (Off lease (free), per week )INDICATE WHAT DOG WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (Off lease (free), per week )AMOUNT OF TIME per DAY or PER WEEK DOG SPENDS at this Site/Activity (ASLEEP)INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (ASLEEP)INDICATE WHAT DOG WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (ASLEEP)AMOUNT OF TIME per DAY or PER WEEK DOG SPENDS at this Site/Activity (OBEDIENCE TRAINING, per week )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (OBEDIENCE TRAINING, per week )INDICATE WHAT DOG WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (OBEDIENCE TRAINING, per week )What is your pet’s favorite toy?*What is your pet’s favorite game?*TrainingDescribe any obedience training*Age at which obedience training started*Success at obedience training:* Poor Fair Moderate Excellent What commands (if any) work best now?*Who in the family has the best control?*HANDLINGCheck how your dog responds to the following tasksNail Trim* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Giving pill* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Cleaning Ears* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Bathing* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Patting Head* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Grasping Collar* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Being Lifted* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Grooming* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Rolling Over* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*CORRECTIONSTYPE of Correction ( Time Out )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Leash Corrections )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Verbal Scolding )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Water Sprayer )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Spanking )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Rollover )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse Other TYPE of CorrectionOTHER PROBLEMSCheck any unwanted behaviors that your dog exhibits: JUMPING UP Barking Housesoiling Urine Tail Biting Chewing Howling Housesoiling Feces Tail Chasing Digging Whining Stool Eating Staring Describe unwanted problems in greater detailATTACHEMENT AND SEPARATIONDescribe how your dog reacts to the following times when left aloneAlone: people gone (M-F) daytime: Amount of Time? Location? Reaction?*Alone: People gone (M-F) evenings: Amount of Time? Location? Reaction?*Alone, people gone (Sat, Sun), evenings : Amount of Time? Location? Reaction?*Alone, People gone (Sat, Sun), daytime: Amount of Time? Location? Reaction?*Have you ever used a crate for confinement?* Yes No Do you still use a crate?* Yes No What is your pet’s reaction to your departure?*What is your pet’s reaction to your homecoming?*Fear and AnxietyIndicate if your pet exhibits any of the following behaviors and the contexts in which they occur (for example: thunderstorms or men with beards) Cowering*Ears Back*Tail Tucked*Retreating*Hiding (under bed, behind couch)*Whining / Crying in distress*Excessive Panting*Excessive Salivation*Pacing*Please make any additional comments regarding fear or anxiety in your dog:Describe any situation in which your dog seems fearful and aggressive:AggressionIndicate your dog’s response to the following situations. Check all that have ever applied: When dog is approached while eating* No Response Growls Barks Lifts Lip Snaps When dog is approached while chewing on a rawhide chew or special treat or toy* No Response Growls Barks Lifts Lip Snaps When taking away a stolen object or rawhide* No Response Growls Barks Lifts Lip Snaps When dog is scolded* No Response Growls Barks Lifts Lip Snaps When dog is spanked* No Response Growls Barks Lifts Lip Snaps When dog is pushed off furniture (bed, couch)* No Response Growls Barks Lifts Lip Snaps When dog is approached while resting/sleeping* No Response Growls Barks Lifts Lip Snaps EVER.. to family members?* No Response Growls Barks Lifts Lip Snaps To strangers outside house/yard or at the door* No Response Growls Barks Lifts Lip Snaps To people entering house/yard* No Response Growls Barks Lifts Lip Snaps EVER, to children or infants* No Response Growls Barks Lifts Lip Snaps While in car, to persons outside car* No Response Growls Barks Lifts Lip Snaps To painful stimuli (ex: injection by veterinarian)* No Response Growls Barks Lifts Lip Snaps To other dogs* No Response Growls Barks Lifts Lip Snaps Has your dog every been reported to local animal control authorities or public health department for biting?* Yes No
