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Dog behaviour questionaire
1.
Owner details
Name
Address
City/Town
ZIP/Postal Code
Email Address
Phone Number
2.
Patient details
Name
Breed
DOB
Sex
Desexed
3.
Referring veterinarian information
Clinic name
Clinic phone number
4.
Trainer information
Trainer's name
Trainer's phone number
5.
How did you find us?
Referred by vet
referred by trainer
web site
word of mouth
saw the clinic
Other (please specify)
6.
Please list the problems you are concerned about (we will deal with each of these in more detail later)
Problem one
Problem two
Problem three
7.
Regarding problem one
Problem
How often does it occur?
When did it start?
When and where does it occur?
Is the problem getting worse?
Any other comments about the problem?
8.
Regarding problem one how serious is the problem?
not very serious
somewhat serious
serious
very serious
extreme
9.
Regarding problem two
Problem
How often does it occur?
When did it start?
When and where does it occur?
Is the problem getting worse?
Any other comments about the problem?
10.
Regarding problem two how serious is the problem?
not very serious
somewhat serious
serious
very serious
extreme
11.
Regarding problem three
Problem
How often does it occur?
When did it start?
When and where does it occur?
Is the problem getting worse?
Any other comments about the problem?
12.
Regarding problem three how serious is the problem?
not very serious
somewhat serious
serious
very serious
extreme
13.
People, please list the people living in your house starting with yourself
Name
Gender
Age
Relationship to yourself
Occupation
Name
Gender
Age
Relationship to yourself
Occupation
Name
Gender
Age
Relationship to yourself
Occupation
Name
Gender
Age
Relationship to yourself
Occupation
Name
Gender
Age
Relationship to yourself
Occupation
Name
Gender
Age
Relationship to yourself
Occupation
14.
Please list any other pets currently living in the household
Name
Species
Age
Sex
Desexed?
Name
Species
Age
Sex
Desexed?
Name
Species
Age
Sex
Desexed?
Name
Species
Age
Sex
Desexed?
15.
All these questions refer to the patient coming in for the consultation
What age did you acquire your pet?
From where?
If a rescue do you know why they were surrendered?
Did they go to puppy pre school?
If so where?
Was your puppy well socialised for the first few months of life?
Does you dog like meeting new dogs on lead?
Does your dog like meeting new dogs off lead?
Has your dog ever been involved in a fight?
16.
Does your dog like people? Tick all that apply
Family
Strangers at home
Strangers on the street
Children
Babies
*
17.
Has your dog ever bitten anyone?
(Required.)
Yes
No
18.
If yes please give details
19.
Has your dog's personality changed over time? If so how?
20.
What rewards do you use for your dog (food,praise, ball etc.?)
21.
What is your dog's favourite pastime?
22.
Where is your pet when you are not at home?
23.
Where does your dog sleep at night?
24.
Is your dog crate trained
Yes
No
25.
What do you feed your dog?
26.
Do you ever feed bones?
Yes
No
27.
How does you dog react to
Loud noises
The car
New places
28.
In one or two words describe how you view your dog's personality
29.
Does you dog chase its tail excessively?
Yes
No
30.
Pace excessively?
Yes
No
31.
Try to escape when you aren't at home?
Yes
No
32.
Bark when you aren't at home?
Yes
No
33.
Show destructive behaviour when you aren't at home?
Yes
No
34.
Eat when you aren't at home?
Yes
No
35.
Toilet inside?
Yes
No
*
36.
Has your dog ever been the subject of a court order?
(Required.)
Yes
No
37.
Been issued a dangerous dog notification?
Yes
No
38.
What sort of collar or harness do you use to walk your dog?
39.
Have you attended dog training? If so briefly describe the training & how it went.
40.
Have you ever used deterrent devices such as shock or citronella collars or remote devices including spray bottles?
Yes
No
41.
If you answered 'yes' to the previous question please describe what you have used
42.
Do you use food toys/puzzles or other enrichment toys? If so which ones?
43.
Patient medical history, (please give details) does your dog have
Pre-existing medical conditions
Chronic pain
Current medication
Blood test in last 12 months
Previous behavioural medications
Any non prescription medications including natural remedies or food additives
44.
Anything else you would like to add about your pets behaviour?
45.
Can you please bring a rough sketch of the floor plan of your house and yard to the appointment to help devise a management strategy specific to your household?
Yes
No
46.
Which of these statement applies to you?
I am only here out of curiosity: the problem is not serious
I would like to change the problem but it is not serious
The problem is serious: I would like to change it but if it remains unchanged that is alright
The problem is very serious: I would like to change it but if it remains unchanged I will keep my dog
The problem is very serious: if it remains unchanged I will euthanase or rehome my dog
*
47.
During our consultation we will be discussing tolerance of risk. Do you understand that in treating behavioural problems there is always some element of risk? While treatment will address that risk it can never completely eliminate it.
(Required.)
Yes
No
Current Progress,
0 of 47 answered