Behavior History Form
Name Address
Date City State Zipcode
Phone Email
Name of Dog Breed Age Sex Weight lbs
Neutered/Spayed Age at Neutering
What brand of food do you feed? Dry Food Canned Food
How much How Often
Age of Dog when Acquired Where
Number of Previous Homes
Other Family Members and ages
Other pets and ages
Name any and all collars/harnesses/leashes you have used.
Do you feel they have been effective in controlling your dog? Yes No
What equipment have you used in the past?
Has your dog ever bitten anyone? Yes No
Who and where did the dog bite? Describe the circumstances.
How does your dog relate to other family members and pets? Good Bad Describe the relationship with other family members and pets:
Medical History
How were you referred?
Veterinarian Information:
Veterinarian's name
Veterinarian's address
Veterinarian's phone
Date of last Vet Visit
Current Medication and doses
Dog's reaction to Vet visit
Behavior Triggers:
Dog's reaction to strangers
Dog's reaction to other dogs
Dog's reaction to squirrels/rabbits etc.
Dog's reaction to infants
Dog's reaction to small children
Dog's reaction to older children
Dog's reaction to bicycles/skateboards/rollerblades
Dog's reaction to cars
Dog's reaction to large vehicles
Known Previous History
Description of Problems/Incidents
Age of Dog when problems first arose
Date of very first occurance
Was any event associated with the onset of the behavior?
Can you interupt the behavior?
What have you done to stop the behavior?
How often does the behavior occur?
What seems to trigger the behavior?
Over time has the behaviour gotten Better Worse Stayed the Same
Describe your goals for your dog
You may be asked to change routine care and procedures such as exercise and interaction with your dog and to work Behavior Modification procedures into your daily activities. Are you willing and able to do this along with dedicating at least 15 minutes of rote training for basic commands daily? Yes No
Have you consulted with a trainer/behaviorist or been to any classes?
If yes, Who? When? Where?
Describe a 24 hour routine
Where does the dog sleep?
Does your dog go to dog parks, daycare or stay with anyone?
What is the schedule for this?
What commands/tricks does your dog know and do willingly?
How do you praise your dog?
Is your dog afraid of anything?
If so, describe how your dog acts
Added comments
The following questions are for past history. Do not attempt to try them at this time. Please mark the appropriate box if your dog has exhibted any of the listed behaviors in the past at any time when you or any memberof the family has done the following:
Touch dog's food or add food while eating Growl Lift Lip Snap Bite No aggression Not tried
Walk past dog while eating Growl Lift Lip Snap Bite No aggression Not tried
Take away real bone, rawhide or delicious food Growl Lift Lip Snap Bite No aggression Not tried
Walk by dog when the dog has a real bone, rawhide, or delicious food Growl Lift Lip Snap Bite No aggression Not tried
Touch delicious food when dog is eating Growl Lift Lip Snap Bite No aggression Not tried
Take away a stolen object Growl Lift Lip Snap Bite No aggression Not tried
Physically wake dog up or disturb resting dog Growl Lift Lip Snap Bite No aggression Not tried
Restrain dog when it wants to go someplace Growl Lift Lip Snap Bite No aggression Not tried
Lift dog Growl Lift Lip Snap Bite No aggression Not tried
Pet dog Growl Lift Lip Snap Bite No aggression Not tried
Medicate dog Growl Lift Lip Snap Bite No aggression Not tried
Handle dog's face/mouth Growl Lift Lip Snap Bite No aggression Not tried
Handle dog's feet Growl Lift Lip Snap Bite No aggression Not tried
Trim the dog's toenails Growl Lift Lip Snap Bite No aggression Not tried
Groom Dog Growl Lift Lip Snap Bite No aggression Not tried
Bathe or towel off Growl Lift Lip Snap Bite No aggression Not tried
Take off or put on collar Growl Lift Lip Snap Bite No aggression Not tried
Hold dog by the muzzle Growl Lift Lip Snap Bite No aggression Not tried
Stare at the dog Growl Lift Lip Snap Bite No aggression Not tried
Reprimand dog in a loud voice Growl Lift Lip Snap Bite No Aggression Not Tried
Visually threaten dog with newspaper, hand, etc. Growl Lift Lip Snap Bite No aggression Not tried
Hit the dog Growl Lift Lip Snap Bite No aggression Not tried
Walk by dog in crate Growl Lift Lip Snap Bite No aggression Not tried
Walk by talk to dog on furniture Growl Lift Lip Snap Bite No aggression Not tried
Physically remove dog from furniture Growl Lift Lip Snap Bite No aggression Not tried
Make dog respond to command Growl Lift Lip Snap Bite No aggression Not tried
Does your dog get a glazed look in his eyes?
Do you consider your dog hyperactive?
History
Did you acquire your dog after 3 months of age? Yes No Don't Know
Did you acquire your dog at 5 weeks or less? Yes No Don't know Was your dog acquired from a shelter or pound? Yes No Don't Know Has your dog had multiple owners during his/her life? Yes No Don't Know
Was your dog acquired from a pet shop? Yes No Don't Know
Was your puppy an orphan or hand raised? Yes No Don't Know
Was your dog the single puppy in a liter? Yes No Don't Know
Behavior
Does your dog follow you around the house? No Mild Moderate Severe
Does your dog become anxious at the sound of car keys? No Mild Moderate Severe
Is your dog anxious when you put on coat or shoes? No Mild Moderate Severe
Does your dog become aggressive when you leave? No Mild Moderate Severe
Does your dog exhibit other problem behaviors as you prepare to leave? No Mild Moderate Severe
Does your dog bark or whine excessively within 30 minutes of your departure? No Mild Moderate Severe
After you leave does your dog's activity level decrease? No Mild Moderate Severe
After you leave does your dog appear depressed? No Mild Moderate Severe
After you leave does your dog have a loss of appetite? No Mild Moderate Severe
Only in your absence does your dog destroy property? No Mild Moderate Severe
Only in your absence does your dog urinate or defecate in your home? No Mild Moderate Severe
Does your dog regularly have diarrhea, vomit, or lick excessively in your absence? No Mild Moderate Severe
Does your dog exhibit an excessive greeting on your return (jumping, hyperactivity, barking, more than 2 or 3 minutes? No Mild Moderate Severe