Canine History Form
The information you provide below will be used during your consultation to develop a diagnosis and
plan of treatment. Please fill it out as completely as you can. All information will be held in strict
confidence and will not be released to any third party without your written consent.
Please return at least 2 business days prior to your dog’s appointment by fax, mail or e‐mail to:
Email:
drbeth@vetbehaviorsolutions.com
mmmmm
Fax:
(877)
240-4543
Mail:
Beth L. Strickler, MS, DVM
Veterinary Behavior Solutions
169 Townsend Road
Fall Branch, TN 37656
Today’s Date
Your Contact Information
Your name:
Phone numbers:
(home)
(work)
Address:
(cell)
(fax)
E‐mail:
Your Family Veterinarian’s Contact Information
Family Veterinarian:
Hospital Name:
Hospital Address:
Veterinarian’s Phone Number:
Your Dog’s Information
Dog’s name:
Breed:
__________________________
Dog’s Birthdate:
Weight:
Sex:
Male

Female
Color:
_
Spayed or castrated? 
No

Yes
Age at which spayed or castrated: ___________________
How old was your dog when you acquired him/her?_________________________________________
% time indoors:
% time outdoors: ________________________
_
Of the total time spent indoors, how long is the dog in a crate?
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Behavior History
What is the main behavioral problem or complaint?
How serious would you rank this behavior?

Very serious

Serious

Not serious
How often does this behavior occur?

Daily

Weekly

Monthly
Please give a detailed description of the most recent incident:
Date of occurrence:
Please give a detailed description of the very first incident you remember:
Date (or approximation) of occurrence:
How old was your dog when he/she first began showing signs of this behavior?
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How long has the behavior been going on? _______Days _______Months _______Years
Have there been changes in frequency or exhibition of the behavior problem?
What steps have been taken to resolve the behavior problem?
What will you do if this behavior cannot be corrected?
Please list any other behavior problems:
What is your goal for this consultation? What would you like to see accomplished?
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Medical History
Please describe any previous or current medical problems of the dog:
Is your dog currently on any medication or special diet? 
No 
Yes
Please list all (include heartworm prevention and flea medications):
Please list all vaccines given within the last year (include dates given):
Your Dog’s Environment
Please describe all the people living in the household now, starting with yourself:
On a scale of 1 to 10, describe the
Hours away from
First Name
Sex
Age
relationship with the dog
home per day
1 = hate 10 = love
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What is the type of area in which you live? 



City/Town Suburban

Rural
What type of home do you live in? 
Apartment

Duplex

Single Family 
Farm
Has the household changed since the dog was acquired? 
No 
Yes
If ‘yes’, please describe (such as addition of family member, addition of pet, move, etc.):
How many times have you moved with this dog since acquiring him/her?
Were there previous owners of this dog? 
No Yes
If ‘yes’, how many?
Reason for surrendering dog?
Diet and Feeding
Feeding
Type of food consumed: 
Canned

Moist

Dry
Brand of food?
Supplements/snacks?
Has there been a recent diet change? 
No Yes
If ‘yes’, from what?
When?
When is your dog fed? (please list times)
Where is your dog fed?
Who feeds your dog?
When is your dog offered treats?
Please describe your dog’s appetite:

Normal

Excessive
Water
Where is the water bowl located?
Water intake: 
Normal

Excessive

Poor
Other
Does this dog ever steal food from: Counters?
Garbage?
No

No
Yes
Yes
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
Human food

Poor
Your Dog’s Daily Routine
Sleeping
Where does your dog sleep?
Does your dog sleep all night long? 
No

Yes
Daytime
During the day, where does your dog spend time?
Hours indoors:
Hours outdoors:
If indoors:

in a crate

free roaming
If outdoors: 
on leash pen

free roaming
What type of fence do you have?

No fence invisible/underground physical fence; how tall?
Is the dog allowed on the furniture in the house? If so, what?
Are there any areas of the house which are off limits to the dog?
Exercise
Type(s) of exercise:
How many hours per day?
How many days per week?
With which family members?
What is your dog’s activity level in general?

Low

Average 
High
Excessive
List the types of toys your dog has and indicate which toys are preferred or are your dog’s
favorites:
Please list other activities you currently engage in with your dog:
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Other Animals
List all animals in the household in the order they were acquired, including pets who have died
within the last year:
Age when
Indoor or outdoor?
obtained
Name
Species
Breed Sex
Age
Please describe relationships between above pets and dog being evaluated:
These pets groom the dog in question:
These pets eat with the dog in question:
These pets play with the dog in question:
These pets fight with the dog in question:
Does your dog play with other pets outside the family? If so, please describe:
Has your dog ever bitten another animal? If so, please describe:
Please describe other pertinent relationships:
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Training
Is the dog house-trained? 
No Yes
Age when housetrained?
Has the dog ever been crate-trained?

No Yes
How would you categorize your dog’s learning ability?
 
Good learner 
Fair learner Poor learner
Has your dog attended obedience classes?


No Yes
Age when attended?
Where and what trainer?
Family members who attended obedience class with dog:
Please describe dog’s interaction with other people at class:
Please describe dog’s interaction with other animals at class:
What commands does your dog know? Please check all that apply:

Sit

Down/Lay
Stay
If so, distance
feet
If so, with owner out of sight?

Yes
No
Heel
Come
If so, onleash?

Yes
No
If so, off leash?

Yes
No

Other, please describe:
Please list any tricks/tasks your dog can perform:
Your Dog’s Interaction with People
Has this dog ever bitten anyone? 

No
Adult
If ‘yes’, what were the circumstances?
Child
How does your dog greet you when you return home (i.e., jump on you, run in circles, hide, wag tail,
etc.)?
Is this dog afraid of: 

Adults
If so, please describe:
Children


Objects
Does your dog like to be held by family members?
If ‘yes’, by whom:


Loud noises

No
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
Yes
Other:
Does your dog like to be brushed and groomed?
If ‘yes’, by whom:

No

Yes
For the following behaviors, please check one or more of the boxes under these descriptions:
NR = no reaction
M = mutter/grumble with mouth closed
B
= bark in a threatening manner
G
= growl with mouth closed, no teeth showing
SL = snarl/rumble with teeth showing (mouth open or closed)
SN = snapping, teeth close rapidly without contacting person
BT = teeth close rapidly and contact person (may/may not leave mark)
ND = never done
***IMPORTANT *** IF YOU HAVE NEVER DONE SOME OF THESE TASKS, DO NOT TRY THEM***
What is your dog’s response when you or a family member does the following?
Type of Behavior
NR
Take dog’s meal away while he/she is eating
Add food to bowl while dog is eating
Take away dog’s favorite toy
Pet the dog
Trim dog’s nails
Lift or try to lift dog
Grab dog by collar
Hug or kiss dog
Scold dog verbally
Restrain dog
Push on dog’s back
Bathe dog
Push on dog’s rump
Wipe dog’s face
Wake dog when sleeping
Please add any other information you feel is pertinent:
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M
B
G
SL
SN
BT
ND