Name: Abbey Animal Hospital
Address: 1949 Lynnhaven Pkwy #1524, Virginia, VA23453
Telephone: +1-(757) 471-1003
Price range: $$

Comments
This field is for validation purposes and should be left unchanged.
Name*
First Last
Pet’s Name*
Today’s Date*
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 Hospital
Phone
Principal Behavioral Complaint
Summarize 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:*
FREQUENCY
Please 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 INFORMATION
At 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*
TECHNIQUES
What 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 HOUSEHOLD
List 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 HOUSEHOLD
List 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.”)*
DIET
Brand 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/EXERCISE
AMOUNT 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?*
Training
Describe 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?*
HANDLING
Check how your dog responds to the following tasks
Nail 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*
CORRECTIONS
TYPE 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 Correction
OTHER PROBLEMS
Check 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 detail
ATTACHEMENT AND SEPARATION
Describe how your dog reacts to the following times when left alone
Alone: 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 Anxiety
Indicate 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:
Aggression
Indicate 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

Small Mammal History Form

Principal Behavioral Complaint

FREQUENCY

BACKGROUND INFORMATION

TECHNIQUES

PERONS LIVING IN THE HOUSEHOLD

PETS LIVING IN THE HOUSEHOLD

DIET

LOCATION/ACTIVITY/EXERCISE

Training

HANDLING

CORRECTIONS

OTHER PROBLEMS

ATTACHEMENT AND SEPARATION

Fear and Anxiety

Aggression

Have Questions?
We’ll Reply Quickly.

This site uses tracking technologies

Small Mammal History Form

Principal Behavioral Complaint

FREQUENCY

BACKGROUND INFORMATION

TECHNIQUES

PERONS LIVING IN THE HOUSEHOLD

PETS LIVING IN THE HOUSEHOLD

DIET

LOCATION/ACTIVITY/EXERCISE

Training

HANDLING

CORRECTIONS

OTHER PROBLEMS

ATTACHEMENT AND SEPARATION

Fear and Anxiety

Aggression

Have Questions? We’ll Reply Quickly.

This site uses tracking technologies

Accessibility Tools

Have Questions?
We’ll Reply Quickly.