Canine Behavior Questionnaire

Client and Pet Information
Please list the problem behavior(s). Please note the relevant degree of concern:
Degree of concern
Degree of concern
Degree of concern
Please note if this behavior occurs:
Has the frequency or intensity of the occurrence of the behavior changed since the problem started?
Duration of problem:
Are you concerned that you may have caused this problem?
Do you feel guilty about this problem?
Have you considered finding another home for your dog?
Have you considered euthanasia (putting your dog to sleep)?
Your Dog's Beginning
Has your dog had previous owners?
How did you acquire your dog? 
Has he/she ever been bred?
Any noted behavioral changes after breeding?
Do you plan on breeding him/her?
Any behavioral changes noted after neutering?
Your Dog's Health
Has your dog been diagnosed with a previous health issue or long-term health concern?
Please list all medications and supplements you are giving to your dog:
Your Dog's Home Life
How is your dog exercised? Please check all that apply  
Where does your dog sleep? Please check all that apply:
Has your household changed since acquiring your dog?
If yes, how so? Check all that apply
Please list the people, including yourself, currently living in the household now:
Please list the animals in the household
Sex
Sex
Sex
Your Dog's Genetic History
Your Dog's Education, Skills and Credentials
How well is your dog trained to eliminate in the appropriate locations?
What is your dog's training history? 
How well does your dog do with the following requests?
Primary Behavioral Screening
Please describe in detail how you prepare to leave the house when your dog will be left alone.
Does your dog exhibit destructive behavior when left alone?
Does your dog urinate or defecate in the home when left alone?
Does your dog bark, howl, whine, or other forms of vocalizing when left alone?
Do you have the ability to remotely view your dog when left alone?
What does your dog do when there is a thunderstorm? Please check all that apply:
Does your dog react to other aspects of storms such as Wind, Rain, Hard Rain or Change in barometric pressure? Please check all that apply:
What does your dog do when there are fireworks? Please check all that apply:
Secondary Behavioral Screening
If you answered "yes" to any of the above questions, please answer the additional questions.
Aggression Screening
Please answer each question using the following information as it fits your dog:
  • NR - No reaction
  • S - Snarl (noise)
  • L - Lift lip (can see teeth)
  • B - Bark (aggressive, not alert)
  • G - Growl (not a play growl)
  • SP - Snap (no connection with skin)
  • BT - Bit 
  • WD - Withdraw or avoid
  • NA - Not applicable; your dog has never been in this situation
Note: A "person" can include the primary owner, a family member, a family friend or an unfamiliar person. A dog can include a household member, a neighbor, another family member's dog or an unfamiliar dog.
How does your dog behave when:
Therapy History
This portion is designed to assist in evaluating any role previous treatments may play in either your dog's problems or in their resolution.

If you answer yes to any of these questions, please indicate who recommended the treatment and if you attempted it, and indicate the outcome.
 
Thank you for taking the time to carefully complete this form.
Information and knowledge are powerful. Gaining this information is the first step in helping your dog to be healthy and happy.  
We look forward to reviewing and discussing your answers with you soon.