VETERINARY BEHAVIOR CONSULTATIONS OF COLORADO
E’Lise M Christensen Bell, DVM DACVB
Ariel Fagen, DVM
21448 E Crestridge Pl
Centennial CO 80015
Phone (720) 306-9601 Fax (720) 306-9602
www.BehaviorVets.com Email BehaviorVets@gmail.com
CANINE BEHAVIOR HISTORY
Thanks to many behaviorists and, especially, the Animal Behavior Clinic at Cornell University for contributing to this history form.
* = required information
CLIENT INFORMATION
Primary Owner Name
Address 1
Address 2
City ST ZIP
Email Address
Phone(s)
Other Owner’s Name
Address 1
Address 2
City ST ZIP
Email Address
Phone(s)
Consultation Location (required for housecall)
Pet Name
Species
Breed
Age and DOB
Color
Male/Female
Neutered/Spayed
Last Weight and Date
Veterinarian
Clinic Name
Address 1
Address 2
City ST ZIP
Email Address
Phone
Req Data Entry
*
) ______-________  Cell
2nd: (
) ______-_________  Cell
1st: (
) ______-________  Cell
Same as above.
2nd: (
) ______-_________  Cell
1st: (
*
*
Dog
______Yrs
_____/_____/______
When adopted? ______________
 Male  Female
 Intact  Neutered/Spayed If so, at what age or when? __________
_______ lbs  kg
Date last weighed: _____/_____/______
Office: (
) ______-________
Fax: (
) ______-________
Referred by
v 3-2-2015
Page 1 of 25
BEHAVIOR CONCERN
*
Rank your dog’s behavior(s) of concern to you, how much of a problem you consider the behavior, and when you first noted.
1
*  Very serious  Serious  Annoying First Noted:
2
 Very serious  Serious  Annoying First Noted:
3
 Very serious  Serious  Annoying First Noted:
4
 Very serious  Serious  Annoying First Noted:
5
 Very serious  Serious  Annoying First Noted:
Describe concerns in order of occurrence.
FIRST behavior incident you remember:
Date and time?
Who was present?
What occurred?
Dog’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
MOST RECENT incident in same detail:
Date and time?
Who was present?
What occurred?
Dog’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
SECOND MOST RECENT incident in same detail:
Date and time?
Who was present?
What occurred?
Dog’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
THIRD MOST RECENT incident in same detail:
Date and time?
Who was present?
What occurred?
Dog’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
OTHER significant incidents:
Date and time?
Who was present?
What occurred?
Dog’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
v 3-2-2015
*
Page 2 of 25
Describe the ranked concerns by intensity, frequency and your response to the concern.
Concern #1
*
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Concern #2
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Concern #3
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Concern #4
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Concern #5
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Note the various disciplinary techniques you
*
use for these behaviors and other problems.
v 3-2-2015
Page 3 of 25
HOUSEHOLD
*
Name any people living in your household.
Name the other animals in the house in the
sequence obtained.
Age
Occupation
Relationship to each other
*
Species
Breed
Age at
adoption
Hrs away
from home
Age now
Describe your dog’s relationship with the other
animals, i.e., friendly, hostile, fearful, etc.
Describe the locale where your dog spends
most of his/her time.
Describe the type of dwelling where your dog
spends most of his/her time.
*Include a floor plan of each level of the main
residence.
Describe the location and floor plan of any
secondary residence/vacation home.
City/town
 Suburbs
Rural
Studio/
1 BR
2 BR Apt/
condo
Townhouse House/
duplex
trailer
Ranch/
Farm
If your dog travels frequently, describe the
method of travel and how tolerated.
How many times have you moved since
acquiring your dog?
Describe changes in environment.
Describe how your household, including
people/animals, has changed since acquiring
your dog.
v 3-2-2015
Page 4 of 25
DOG’S BACKGROUND
Why did you decide to get a dog?
Have you owned dogs before?
Why did you choose this breed, sex, color?
Where did you get this dog?
*
 Shelter/
rescue
 Stray
 Friend
 Newspaper  Serious
 Pet store
Breeder
 Breeder
 Backyard
Referral
Breeder
_____Yrs
 Yes  No
If so, describe.
Other – describe.
If known, how many littermates?
Male/female?
How many did you choose from?
Specifically, why this dog over others?
Describe any temperament test or behavioral
evaluation performed.
Describe your dog’s behavior as a puppy.
Favorite time and activity to share?
Best behavior performed?
Has the dog had other owners?
How many?
Why was the dog given up?
If your dog is intact, has he/she ever been
bred?
Are you planning to breed?
If you have an intact female, when was her last
heat? Was it normal?
At what age was your dog neutered/spayed?
Were there behavior changes after neutering?
v 3-2-2015
Page 5 of 25
MEDICAL HISTORY
Previous Illness/Injury
Has your dog ever been diagnosed with a
seizure disorder?
Does your dog have any problems with skin or
ears, i.e., scratching, redness, greasy, hair loss,
etc.?
Has your dog ever been diagnosed with any
bone or muscle problems?
Does your dog have chronic sneezing or
coughing?
Does your dog have periodic diarrhea or
gastrointestinal distress?
Medications used in the past for
MEDICAL problems:
*
Date of onset Date resolved
 Yes
 No
If so, describe:
 Yes
 No
If so, describe:
 Yes
 No
If so, describe:
 Yes
 No
If so, describe:
 Yes
 No
If so, describe:
Medications and doses used
Dose and frequency
Date begun/
ended
Side-effects
Medications used in the past for
BEHAVIORAL problems:
Dose and frequency
Date begun/
ended
Side-effects
List any supplements you have tried or are
currently administering for any problems.
Dose and frequency
Date begun/
ended
Side-effects
v 3-2-2015
Page 6 of 25
DIET AND FEEDING
*
What do you feed your dog?
Brand
Amount
Where
Time of day
How has your dog’s appetite changed?
 Increased  Decreased  No change. If so, describe.
Who feeds the dog?
Where?
Where does your dog drink?
List your dog’s five favorite treats from the
most to least including any human food treats
your dog likes.
How often do you give treats? For what?
Most
DAILY SCHEDULE
Describe a typical 24-hr day in your dog’s life.
How does your dog behave with familiar
visitors?
With unfamiliar visitors?
Does your dog behave differently with
children?
Differently with familiar vs unfamiliar children?
Differently with toddlers and babies?
How do you exercise your dog?
How do you play with your dog?
What toys does the dog have?
What toys does your dog prefer?
How many exercise/walk sessions does your
dog get daily? For how long?
How many play sessions does your dog get
daily?
How many training sessions does your dog get
daily?
How often do you groom your dog? Take the
dog to the groomer?
Is your dog housetrained?
Does your dog ever eliminate in the house?
Does your dog jump on you or others without
permission?
Paw at you or others?
Lick you?
Mount?
Does your dog ever bark at you?
Bark at other times?
What is your dog’s activity level in general?
v 3-2-2015
% Protein
(from dog
food label)
Least
*
 Runs free
 Runs free
but supv.
 Fenced
yard
 Kenneled
run
 Leash
walked
 Tied
outside
 Walks
 Indoors
only
 Dog park
 Outdoors
only
 Yes  No If so, how?
 Urinate  Defecate  Both  No
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Low
 No
 No
 No
 No If so, whom and/or what?
 No If so, describe.
 No If so, describe.
 Average  High  Excessive If so, describe.
Page 7 of 25
SOCIAL BEHAVIOR
Specifically where does your dog sleep at
night?
Where is his/her favorite sleep spot?
Has your dog’s sleep changed in pattern or
length?
Have you ever used a crate or room to confine
your dog?
Do you still use the crate or room?
Where is your dog when alone in the house?
When you have guests?
What percentage of the day does your pet
spend inside?
Outside?
How does your dog behave while you are
leaving the house?
When you return?
v 3-2-2015
*
 Yes
 No
If so, describe.
 Yes
 No
If so, describe your dog’s reaction.
 Yes
 No
If so, what for? If not, why?
Page 8 of 25
TRAINING
What training has your dog had?
How old was your dog when training started?
*
 None
 HomeTaught
 Agility
 Flyball
 Private
______ Yrs
What type of training collar was used?
 Started
class
Graduated
Class
Graduated
2+ classes
Other – describe.
Trainer’s
Name
Describe
Response
None (off leash)
Neck collar
Remote collar (shock, citronella)
Head halter
Body harness
Who in the family is the primary trainer?
Have you or do you plan to exhibit your dog in
Yes No
If so, describe.
breed shows or dog sports?
Describe any awards or titles your dog has.
Has your dog had any of these specialized
Hunting
Herding
Protection Attack
training classes?
What percent of the time does your dog obey the following commands for each member of the family?
Family Member Name
Sit
Down
Stay
Come
Grade 1-5
Good-poor
Schutzhund
Heel
(don’t pull)
Yes No If so, describe.
 Reward Assertive/  Aversive/ Other - describe:
Describe the training you tried with your dog.
based
dominance/
mostly
pack style
corrections
Describe your dog’s reaction to any of the following if you have used for punishment OR training.
 Behavior stopped/diminished  Behavior worsened/intensified
Physical contact
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Noise (shaker can, siren)
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Ultrasonic
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Water sprayer
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Verbal reprimands
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Muzzle grasp
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Pinning/alpha roll
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Time-out
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Booby-traps/repellants
Describe.
Punishment
Is any punishment effective?
 Yes  No If so, what?
What punishment is most effective?
Will your dog settle or relax on command?
v 3-2-2015
Page 9 of 25
Are others needed?
Does the behavior decrease in frequency or
intensity over the course you use this
punishment?
Describe any punishment that makes the
problem worse.
Describe any punishment that led to
threatening behavior, aggression or fear.
Does your dog respond differently to
punishment from different family members?
v 3-2-2015
 Yes
 Yes
 No
 No
If so, what?
If so, describe.
 Yes
 No
If so, describe.
Page 10 of 25
AGGRESSION SCREENING
* Fill out even if aggression is not the main problem.
Not all of these situations are appropriate ways to interact with a dog.
Do NOT try these situations if you don’t already know what might trigger your dog.
Screen can be used in several ways: 1) to note presence/absence of a behavior; 2) as a log noting number of occurrences, times
attempted during a period of time; and/or 3) as a log noting frequencies to compare to #2.
Key: None = no reaction Snarl = lifted lip, noise
Bark = aggressive bark Growl = serious, not play Snap = no skin contact
Bite = skin contact Withdraw = cower, avoid N/A = not applicable; never been in that situation
+/- = increasing/decreasing
What is your dog’s response to:
 None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family petting the dog
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family hugging the dog
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family kissing the dog
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family lifting the dog
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family calling off furniture
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family pushing/pulling off furniture
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family approaches on furniture
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family disturbs while resting/sleeping
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family approaches while eating
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family touches while eating
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family takes dog food away
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family takes water dish away
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family takes rawhide
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family takes biscuit/cookie
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family takes real bone
Frequency:  +/ Intensity:  + / Family approaches when dog has any
 None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
object/toy/bone
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family verbally punishes
Frequency:  +/ Intensity:  + / Family poses visual threat, i.e., stare, wave
 None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
arms at dog
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family speaks to dog in normal tone
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family stares at dog
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family bends over dog
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap  Bite  Withdraw  N/A
Family pushes on shoulders or back
Frequency:  +/ Intensity:  + / -
v 3-2-2015
Page 11 of 25
What is your dog’s response to: (cont)
Family approaches dog near spouse
Family enters room
Family leaves room
Family reaches toward dog
Family uses leash restraint
Family uses collar restraint
Family uses scruff restraint
Family takes leash off/on
Family puts collar on/off
Family bathes dog
Family towels dog
Family grooms/brushes dog
Family trims nails
Family uses leash/collar correction
Family uses “sit”
Family uses “down”
Familiar adult enters house/yard
Familiar child enters house/yard
Response to familiar toddler/child
Familiar adult approaches owner and dog on
leash
Familiar child approaches owner and dog on
leash
Stanger petting the dog
Stranger hugging the dog
Stranger kissing the dog
Stranger lifting the dog
Stranger calling off furniture
Stranger pushing/pulling off furniture
Stranger approaches on furniture
v 3-2-2015
 None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + / -
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
Page 12 of 25
What is your dog’s response to: (cont)
Stranger disturbs while resting/sleeping
Stranger approaches while eating
Stranger touches while eating
Strange takes dog food away
Stranger takes water dish away
Stranger takes rawhide
Stranger takes biscuit/cookie
Stranger takes real bone
Stranger approaches when dog has any
object/toy/bone
Stranger verbally punishes
Stranger poses visual threat, i.e., stare, wave
arms at dog
Stranger speaks to dog in normal tone
Stranger stares at dog
Stranger bends over dog
Stranger pushes on shoulders or back
Stranger approaches dog near spouse
Stranger enters room
Stranger leaves room
Stranger reaches toward dog
Stranger uses leash restraint
Stranger uses collar restraint
Stranger uses scruff restraint
Stranger takes leash off/on
Stranger puts collar on/off
Stranger bathes dog
Stranger towels dog
Stranger grooms/brushes dog
Dog at groomer’s
v 3-2-2015
 None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + / -
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
Page 13 of 25
What is your dog’s reponse to: (cont)
Stranger trims nails
Stranger uses leash/collar correction
Stranger uses “sit”
Stranger uses “down”
Adult stranger enters house/yard
Child stranger enters house/yard
Response to toddler/child stranger
Stranger adult approaches owner and dog on
leash
Stranger child approaches owner and dog on
leash
Response to strangers when off leash
Dog at veterinary clinic
Dog in car, sees people/animals at tollbooths,
gas stations
Dog in house, sees people/animals outside
Response on leash to other dogs
Response off leash to other dogs.
Characteristics of Aggressive Episodes
Attacks are sudden and surprising.
Episodes appear unprovoked.
Dog is abruptly docile afterward.
Dog appears “sorry” afterward.
Episodes associated with “glazed” or “absent”
expression.
I can usually tell what will set off my dog.
The behavior is new and uncharacteristic.
Describe a typical aggressive episode, e.g.,
growl, lunge, bite, etc.
What is the usual circumstance?
Given the same situation 10 times, how many
result in aggression?
Has the frequency or intensity of the behavior
changed since the problem started?
Does your dog exhibit periodic diarrhea or
gastrointestinal distress?
v 3-2-2015
 None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Bark  Growl Snap
Frequency:  +/ Intensity:  + / -
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
 Yes
 Yes
 No
 No
0
1
 2-3
 Yes
 No
If so, describe.
 Yes
 No
If so, describe.
 4-5
 6-7
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 Bite  Withdraw  N/A
 8-9
 >10
Page 14 of 25
Episodes of Human-Directed Aggression
If your dog bit as a puppy, at what age?
Describe the first time your dog growled at a
person. At what age?
Describe the first time your dog snapped or bit
at a person. At what age?
If your dog has bitten a human, total number
of bites?
Does your dog bite more than once per
episode?
0
 Yes
1
 No
1
Pre-Bite
(air bite)
2
3
If so, describe:
3
Shallow
Bite
(less than
depth of
canine
tooth)
5
 >5
4
Deep Bite
(depth of
canine
tooth)
5
6
Multiple
LifeBites
threatening
(deep and
(flesh
multiple) consumed
or victim
death)
1
2
3
4
5
1
2
3
4
Pre-Bite
Near Bite
Shallow
Deep Bite
(air bite)
(tooth
Bite
(depth of
contact, no (less than
canine
puncture)
depth of
tooth)
canine
tooth)
 >5
5
6
Multiple
LifeBites
threatening
(deep and
(flesh
multiple) consumed
or victim
death)
Human Bite Levels
2
Near Bite
(tooth
contact, no
puncture)
4
Number of bites by severity?
Number of bites to part of the body?
Face
Torso
Arms
Legs
Who is/are the targets of aggression?
M/F
Infant/Child/Adult
Dark/Light Skin
Tall/Short
Carrying Box/Cane/Umbrella
Hat/Uniform
How many bites to humans were reported?
To whom were they reported, i.e., local
authorities, hospital, human society?
Was legal action taken?
 Yes
Episodes of Dog-Directed Aggression
If your dog has bitten another dog, total
number of bites?
0
Bite Levels
Number of bites by severity?
How many bites to dogs were reported?
To whom were they reported, i.e., local
authorities, hospital, human society?
Was legal action taken?
v 3-2-2015
 Yes
 No
 No
If so, describe:
If so, describe:
Page 15 of 25
ANXIETY AND FEAR REACTIVITY SCREEN
*
Behavior While ACTUALLY Alone or Totally Without the Client
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Destructive behavior
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Inappropriate urination
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Inappropriate defecation
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Vocalization – barking, whining, etc.
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Salivation – drooling, slobbering, etc.
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Panting
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
Behavior While VIRTUALLY Alone, i.e., client is home but not accessible, door closed, etc.
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Destructive behavior
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Inappropriate urination
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Inappropriate defecation
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Vocalization – barking, whining, etc.
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Salivation – drooling, slobbering, etc.
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Panting
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
Reactions to Noise
Thunderstorms
Does your dog react to other aspects of
storms?
Fireworks
Gunshots/backfires
v 3-2-2015
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (bark, whine, growl, howl)
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
Wind
 Yes  No  Don’t know
Darkness
 Yes  No  Don’t know
Ozone
 Yes  No  Don’t know
Barometric pressure
 Yes  No  Don’t know
Rain
 Yes  No  Don’t know
Hail
 Yes  No  Don’t know
 Salivate  Defecate  Urinate
 Always (>95%)  No reaction
 Escape  Pant
 Pace
 Frequently
 Don’t know
 Hide
 Tremble  Destroy
 Occasionally
 Freeze  Won’t eat  Pupils dilate  Rarely
 Vocalize (bark, whine, growl, howl)
 Never
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (bark, whine, growl, howl)
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
Page 16 of 25
Reactions to Noise (cont)
Mechanics, i.e., vacuums, blowers, etc.
Siren/alarms
Cars/trucks
How frequently do noise events occur in the
dog’s environment?
Has this dog ever been treated for noise
sensitivities or phobias?
v 3-2-2015
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (bark, whine, growl, howl)
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (bark, whine, growl, howl)
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (bark, whine, growl, howl)
 Frequently – multiple times per week
 Regularly – almost weekly
 Occasionally – 2-3 times per month
 Almost never – 2-3 times per year
 Yes  No If so, describe:
 Always (>95%)
 Frequently
 Occasionally
 Rarely
 Never
 Always (>95%)
 Frequently
 Occasionally
 Rarely
 Never
 No reaction
 Don’t know
 No reaction
 Don’t know
Page 17 of 25
*
PREVIOUS TREATMENT SCREENING
General Approaches
Obedience class
Private trainer
Agility trainer
Send to a shelter
Place in another home
Euthanize or kill
Consult your vet
Consult a non-veterinary behavior consultant
Consult a veterinary behaviorist (DACVB)
Make into working dog - guard, hunting, etc.
Specific Approaches
Stare at or “stare down”
Grab by jowls and shake
Get a companion dog for this one
Step on leash or choke collar and force down
Blow in nose or face
Provide different types of dog toys
Fabric choke collar
Metal choke collar
Prong collar
Halti, head collar or Gentle Leader
Harness
Pull or Sporn harness
Martingale collar
Scruffy Guider
Electronic or shock collar by owner
v 3-2-2015
Screen is used to evaluate the role previous treatment recommendations
may play in your dog’s problems or in their resolution – first in a general
sense and secondly for specific actions.
Suggested
By whom
Attempted
Outcome
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
Suggested
By whom
Attempted
Outcome
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
Page 18 of 25
Specific Approaches (cont)
Electronic or shock collar by trainer
Remote controlled or bark-activated electronic
or shock collar
Citronella collar
Citronella spray
Throw a tin or can of pennies
Water pistol
Whistle
Foghorn
Hit dog with hand
Blow torch
Hit dog with empty plastic soda bottle
Hit dog with whiffle ball bat
Hit dog with leash
Hit dog with chain
Hit dog with board, plank or baseball bat
Hit dog under chin
Step on dog’s toes
Knee dog in chest/belly
Kick dog
Bite dog
“Alpha roll” (hold spread-eagle on back)
“Dominance down” (hold down on side, legs
extended, head flat)
Growl at dog
Yell or scream at dog
Long down
Sit and wait
“Time out” (where, how and for how long)
Praise for good behavior
v 3-2-2015
Suggested
By whom
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
Attempted
 Yes  No
Outcome
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Page 19 of 25
Specific Approaches (cont)
Crate
Kennel outdoors
Fenced yard
Invisible fence
Isolate in house (where and for how long)
Board at vet
Board at kennel
Whip
Chain
Cattle prod
“String up”, hang by leash and collar (all 4 feet
off ground)
Pop and jerk leash
Yank or pull on leash
Tie up physically
Tie out or stake on very short lead hooked to
wall or floor
Muzzle
Increase exercise
Increase play
Give treats for good behavior
Deprive of food
Throw against wall
Beat with your fists
Shove dog’s nose/face into urine, feces or
destruction
Use scat mats or other electronic avoidance
systems
Calming cap
Thundershirt or Anxiety Wrap
Other:
Other:
v 3-2-2015
Suggested
By whom
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
Attempted
 Yes  No
Outcome
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Page 20 of 25
REPETITIVE BEHAVIORS HISTORY
Grooming
Hallucinatory
Consumptive
Locomotory
Vocalization
Patterns of Repetitive Behavior
Was there a change in the household or an
event associated with the development of the
behavior?
Is there any time of day when the behavior
seems more or less intense?
Is there a person or another pet in the
presence of whom the behavior seems more
intense?
Does the dog respond to its name or seem
aware of the surroundings while in the midst of
the behavior?
Is the dog aware that you are calling him/her?
Can you convince the dog to stop the behavior
by calling him or her?
By using physical restraint?
List the kinds of things, i.e., noises, treats, toys,
if any, that will interrupt the behavior once it
has started.
Is there a location in which the dog prefers to
perform the behavior?
For ingestion, list what types of objects are
consumed – as specifically as possible.
Does any event or behavior routinely occur
immediately BEFORE the behavior begins?
Does any event or behavior routinely occur
immediately AFTER the behavior begins?
Has the dog’s general changed in any way since
the onset of the atypical behavior, i.e., the dog
is more or less aloof, aggressive, withdrawn,
playful, etc.?
Has the dog’s diet recently been changed>
How old do you think your pet was when its
ritualistic behavior began?
v 3-2-2015
*
Complete or check only if your dog is showing repetitive or ritualistic
behaviors that you find troublesome or about which you are concerned.
 Chewing self  Biting self  Licking self  Plucking hair
 Barbering/trimming hair on self
 Continuously doing any of these behaviors to another individual
If so, describe:
 Other If so, describe:
 Staring and fixating on things that are not there
 Tracking things that are not there
 Pouncing on or attacking things that are not there
 Other If so, describe:
 Consuming rocks
 Consuming dirt or soil
 Consuming other objects  Licking or gulping air
 Eating, licking, sucking or chewing wool or fabric, rugs, furniture, etc.
 Other If so, describe:
 Circling/spinning  Tail-chasing  Freezing
 Other If so, describe:
 Rhythmic barking  Howling
 Growling
 Other If so, describe:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail what is going on at that
time of day:
 Yes  No  Uncertain If yes, describe who this is and their association
to the pet?
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
_____Yrs
Page 21 of 25
Patterns of Repetitive Behavior (cont)
Did any other dog in the dog’s family exhibit
these or similar behaviors?
 Yes  No  Uncertain If yes, describe in detail:
Is there a pattern to the behavior?
 Yes  No  Uncertain If yes, describe in detail:
Duration: ____Hrs _____Days _____Wks _____Mos
Pattern – after meals, in AM, etc.:
v 3-2-2015
Page 22 of 25
AGE-ASSOCIATED BEHAVIOR SCREEN
Locomotory/Ambulatory
Appetite
Elimination
v 3-2-2015
Complete ONLY if you have a dog more than 7 years old.
Check only one –
 No alterations or debilities noted.
 Modest slowness associated with change from youth to adult.
 Moderate slowness associated with geriatric aging.
 Moderate slowness associated with geriatric aging plus alteration or
debility in gait.
 Moderate slowness associated with geriatric aging plus some loss of
function, e.g., cannot climb stairs.
 Severe slowness associated with extreme loss of function, particularly on
slick surfaces and may need to be carried.
 Severe slowness, extreme loss of function and decreased willingness or
interest in locomoting – spends most of the time in bed.
 Paralyzed or refuses to move.
May check more than one –
 No alterations in appetite.
 Change in ability to physically handle food.
 Change in ability to retain food (vomits or regurgitates).
 Change in ability to find food.
 Change in interest in food (may have to do with sense of smell).
 Change in rate of eating.
 Change in completion of eating.
 Change in timing of eating.
 Change in preferred textures.
Check only one in each category.
Changes in frequency and “accidents”
 No change in frequency and no “accidents”.
 Increased frequency, no “accidents”.
 Decreased frequency, no “accidents”.
 Increased frequency with “accidents”.
 Decreased frequency with “accidents”.
 No change in frequency but “accidents”.
Bladder control
 No change in urination control or behavior.
 Leaks urine only when asleep.
 Leaks urine only when awake.
 Leaks urine when awake or asleep.
 Full-stream, uncontrolled urination only when asleep.
 Full-stream, uncontrolled urination only when awake.
 Full-stream, uncontrolled urination when awake or asleep.
 No leakage or uncontrolled urination but in inappropriate or undesirable
location.
Bowel control
 No changes in bowel control.
 Defecates when asleep -  formed  diarrhea  mixed
 Defecates without apparent awareness -  formed  diarrhea  mixed
 Defecates when awake and aware of action but in inappropriate or
undesirable locations -  formed  diarrhea  mixed
Page 23 of 25
AGE-ASSOCIATED BEHAVIOR SCREEN (cont)
Visual Acuity
Auditory Acuity
Interactions
Sleep/Wake Cycle
v 3-2-2015
Check only one –
 No change in visual acuity detected by behavior – seems to see as well as
ever.
 Some change in acuity not dependent on ambient light conditions.
 Some change in acuity dependent on ambient light conditions.
 Extreme change in acuity not dependent on ambient light conditions.
 Extreme change in acuity dependent on ambient light conditions.
 Blind.
Check only one –
 No apparent change in auditory acuity.
 Some decrease in hearing – not responding to sounds the dog used to
 Extreme decrease in hearing – have to make sure the dog is paying
attention, repeat signals, go get the dog when called.
 Deaf – no response to sounds of any kind.
Check only one in each category –
Play/Toys
 No change in play with toys.
 Slightly decreased interest in toys.
 Slightly decreased ability to play with toys.
 Slightly decreased interest and ability to play with toys.
 Extreme decreased interest in toys.
 Extreme decreased ability to play with toys.
 Extreme decreased interest and ability to play with toys.
Humans
 No change in interaction with people.
 Recognizes people but slightly decreased frequency of interaction.
 Recognizes people but greatly decreased frequency of interaction.
 Withdrawal but recognizes people.
 Does not recognize people.
Other Pets
 No change in interaction with other pets.
 Recognizes other pets but slightly decreased frequency of interaction.
 Recognizes other pets but greatly decreased frequency of interaction.
 Withdrawal but recognizes other pets.
 Does not recognize other pets.
 No other pets or animal companions in house or social environment.
Check only one –
 No changes in sleep pattern.
 Sleeps more during the day.
 Some change – awakens at night and sleeps more during the day.
 Much change – profoundly erratic nocturnal pattern and irregular daytime
pattern.
 Sleeps virtually all day, awake occasionally at night.
 Sleeps almost around the clock.
Page 24 of 25
FAMILIAL BEHAVIOR HISTORY
If a pedigree is available and any familial behavior history is known, mark each family member –
__ - No known behavior information.
KA – Known affected.
KU – Known unaffected.
TA – Tentatively or possibly affected.
TU – Tentatively or possibly unaffected.
AO – Affected with another behavioral problem.
 No pedigree is available for this dog.
Is a pedigree available?
 There is a pedigree available for this dog but it is not attached.
 Pedigree is attached.
Are any family members known?
 Yes  No If yes, describe.
Are any known family members affected?
 Yes  No
Affected relatives do not have to have the
same form of the condition to be considered
affected. In other words, some dogs may lick
themselves whereas others follow fences or
chase their tails. If you know what other
affected dogs do, describe.
Which statement most accurately describes your feelings about the problem?
 I am here only out of curiosity. The problem isn’t serious.
 I’d like to change the problem but it’s not serious.
 The problem is serious and I’d like to change it but, if it remains unchanged, that’s all right.
 The problem is very serious and I’d like to change it but, if it remains unchanged, I’ll keep my dog.
 The problem is very serious and I’d like to change it and, it if remains unchanged, I’ll euthanize or give up my dog.
If considering rehoming or euthanasia, have you discussed this within the family? With the place where you obtained your dog?
Is there anything else you think we should know?
COMMENTS
Attachments
Floor plan for each residence.
Primary vet medical record
Primary vet laboratory results esp CBC, UA, chem screen, T4 (if ever done)
v 3-2-2015
Page 25 of 25