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
PET 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: (
*
*
Pet
______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 28
BEHAVIOR CONCERN
*
Rank your pet’s behavior(s) of concern to you, how much of a problem you consider the behavior, and when you first noted.
 Very serious  Serious  Annoying First Noted:
1
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?
Pet’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?
Pet’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?
Pet’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?
Pet’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?
Pet’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 28
Describe the ranked concerns by intensity, frequency and your response.
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 28
HOUSEHOLD
Name any people living in your household.
Name the other animals in the house in the
sequence obtained.
*
Age
Occupation
Species
Relationship to each other
Breed
Age at
adoption
Hrs away
from home
Age now
Describe your pet’s relationship with the other
animals, i.e., friendly, hostile, fearful, etc.
Describe the locale where your pet spends
most of his/her time.
Describe the type of dwelling where your pet
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 pet travels frequently, describe the
method of travel and how tolerated.
How many times have you moved since
acquiring your pet?
Describe changes in environment.
Describe how your household, including
people/animals, has changed since acquiring
your pet.
v 3-2-2015
Page 4 of 28
PET’S BACKGROUND
Why did you decide to get a pet?
Have you owned cats before?
Why did you choose this breed, sex, color?
Where did you get this pet?
*
 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 pet over others?
Describe any temperament test or behavioral
evaluation performed.
Describe your pet’s behavior as a kitten.
Favorite time and activity to share?
Best behavior performed?
Has the pet had other owners?
How many?
Why was the pet given up?
If your pet 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 pet neutered/spayed?
Were there behavior changes after neutering?
v 3-2-2015
Page 5 of 28
MEDICAL HISTORY
Previous Illness/Injury
*
Date of onset Date resolved
Has your pet ever been diagnosed with a
seizure disorder?
Does your pet have any problems with skin or
ears, i.e., scratching, redness, greasy, hair loss,
etc.?
 Yes
 No
If so, describe:
 Yes
 No
If so, describe:
Has your pet ever been diagnosed with any
bone or muscle problems?
Does your pet have chronic sneezing or
coughing?
Does your pet have periodic diarrhea or
gastrointestinal distress?
Medications used for MEDICAL problems past
or present
 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 for BEHAVIORAL problems
past or present
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 28
DIET AND FEEDING
What do you feed your pet?
*
Brand
Amount
Where
Time of day
How has your pet’s appetite changed?
 Increased  Decreased  No change. If so, describe.
Who feeds the pet?
Where?
Where does your pet drink?
List your pet’s five favorite treats from the
most to least including any human food treats
your pet likes.
How often do you give treats? For what?
Most
v 3-2-2015
% Protein
(from pet
food label)
Least
Page 7 of 28
ELIMINATION BEHAVIOR
Does your pet use a litter pan?
Does your pet ever eliminate in the house but
outside the litter pan?
Describe your litter pans.
Type
Commercial – size, with removable lip or
“Booda”-type door (pet crawls in hole)?
Found/Devised - dishpan, cardboard box, other
(describe)?
*
 Yes
 Yes
 No
 No
If so, how trained?
If so,  Urinate  Defecate  Both.
#1
#2
#3
#4
#5
Commercial Commercial Commercial Commercial Commercial
Size ______
Size ______
Size ______
Size ______
Size ______
 Lip
 Lip
 Lip
 Lip
 Lip
 Booda
 Booda
 Booda
 Booda
 Booda
Found
Found
Found
Found
Found
Paper box Paper box Paper box Paper box Paper box
Dishpan
Dishpan
Dishpan
Dishpan
Dishpan
 Other:
 Other:
 Other:
 Other:
 Other:
How old?
Liner?
_____Yrs
 Plastic
 Newspaper
 Other:
_____Yrs
 Plastic
 Newspaper
 Other:
_____Yrs
 Plastic
 Newspaper
 Other:
_____Yrs
 Plastic
 Newspaper
 Other:
_____Yrs
 Plastic
 Newspaper
 Other:
Type of litter including brand?
__________
 Clumping
 Clay
 Multi-pet
 Other:
__________
 Clumping
 Clay
 Multi-pet
 Other:
__________
 Clumping
 Clay
 Multi-pet
 Other:
__________
 Clumping
 Clay
 Multi-pet
 Other:
__________
 Clumping
 Clay
 Multi-pet
 Other:
Recently changed brands?
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Water
 Chem sol
 Water
 Chem sol
 Water
 Chem sol
 Water
 Chem sol
 Water
 Chem sol
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 Yes  No
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 Don’t know
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
How often scooped?
How cleaned and how often?
How often is litter replaced?
Does the pet cover urine and feces in the box?
v 3-2-2015
Page 8 of 28
DAILY SCHEDULE
Describe a typical 24-hr day in your pet’s life.
*
How does your pet behave with familiar
visitors?
With unfamiliar visitors?
Does your pet behave differently with
children?
Differently with familiar vs unfamiliar children?
Differently with toddlers and babies?
How do you play with your pet?
What toys does your pet have?
Prefer?
Does your pet go outdoors?
 Yes  No If so, how does your pet signal to go out?
 Yes  No
 Yes  No
Is your pet supervised outdoors?
Is your pet harness/leash trained?
How much time does your pet spend outdoors
daily?
SOCIAL BEHAVIOR
Specifically where does your pet sleep at night?
Where is his/her favorite sleep spot?
Has your pet’s sleep changed in pattern or
length?
Have you ever used a crate or room to confine
your pet?
Do you still use the crate or room?
Where is your pet when alone in the house?
When you have guests?
How does your pet behave while you are
leaving the house?
When you return?
How does your pet behave with adult visitors?
Children?
How does your pet behave with the
veterinarian?
Does your pet respond to cats seen out of the
window or in the yard?
When does your pet meow?
Hiss or growl?
What is your pet’s activity level in general?
If so, how trained?
______  Hrs  %
*
 Yes
 No
If so, describe.
 Yes
 No
If so, describe your pet’s reaction.
 Yes
 No
If so, what for? If not, why?
 Yes
 No
If so, describe.
 Low
 Average
 High
 Excessive
If excessive, describe:
How would you describe your pet’s
personality?
v 3-2-2015
Page 9 of 28
GROOMING
Does your pet groom, lick or bite him/herself
excessively?
Does the pet’s skin ripple?
Is your pet declawed?
If so, what was the aftercare?
Did you use newspaper in the pan?
Did your pet use this litter?
Did the paws become infected after surgery?
Describe your pet’s favorite scratching area or
post?
*
SEXUAL BEHAVIOR
Has your pet ever been bred?
If you have a female, was she a good mother?
If your pet is intact, are you planning to breed?
If your pet is neutered/spayed, at what age?
Were there behavior changes after neutering?
Does your pet mouth other cats, other animals
or people?
*
v 3-2-2015
 Yes
 No
If so, describe.
 Yes
 Yes
 No
 No
If so,  Front only  Both
 Yes
 Yes
 Yes
 No
 No
 No
 Yes
 Yes
 Yes
______
 Yes
 Yes
 No
 No  Unknown If not, describe.
 No  Neutered/spayed
 Months  Yrs
 No  Unknown If so, describe.
 No  Unknown If so, describe.
Page 10 of 28
TRAINING
What training has your pet had?
How old was your pet when training started?
*
 None
 HomeTaught
 Agility
 Flyball
 Private
 Started
class
Graduated
Class
Graduated
2+ classes
Other – describe.
______ Yrs
What type of training collar was used?
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 pet in
Yes No
If so, describe.
breed shows or pet sports?
Describe any awards or titles your pet has.
Has your pet had any of these specialized
Hunting
Herding
Protection Attack
training classes?
What percent of the time does your pet 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 pet.
based
dominance/
mostly
pack style
corrections
Describe your pet’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?
Are others needed?
 Yes  No If so, what?
Will your pet settle or relax on command?
v 3-2-2015
Page 11 of 28
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 pet respond differently to
punishment from different family members
v 3-2-2015
 Yes
 No
If so, describe.
 Yes
 No
If so, describe.
Page 12 of 28
AGGRESSION SCREENING
* Fill out even if aggression is not the main problem.
Not all of these situations are appropriate ways to interact with a pet.
Do NOT try these situations if you don’t already know what might trigger your pet.
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
Hiss = aggressive hiss 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 pet’s response to:
 None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family petting the pet
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family hugging the pet
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family kissing the pet
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family lifting the pet
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family calling off furniture
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family pushing/pulling off furniture
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family approaches on furniture
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family disturbs while resting/sleeping
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family approaches while eating
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family touches while eating
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes pet food away
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes water dish away
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes rawhide
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes biscuit/cookie
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes real bone
Frequency:  +/ Intensity:  + / Family approaches when pet has any
 None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
object/toy/bone
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family verbally punishes
Frequency:  +/ Intensity:  + / Family poses visual threat, i.e., stare, wave
 None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
arms at pet
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family speaks to pet in normal tone
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family stares at pet
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family bends over pet
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family pushes on shoulders or back
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap  Bite  Withdraw  N/A
Family approaches pet near spouse
Frequency:  +/ Intensity:  + / -
v 3-2-2015
Page 13 of 28
What is your pet’s response to: (cont)
Family enters room
Family leaves room
Family reaches toward pet
Family uses leash restraint
Family uses collar restraint
Family uses scruff restraint
Family takes leash off/on
Family puts collar on/off
Family bathes pet
Family towels pet
Family grooms/brushes pet
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 pet on
leash
Familiar child approaches owner and pet on
leash
Stanger petting the pet
Strange hugging the pet
Stranger kissing the pet
Stranger lifting the pet
Stranger calling off furniture
Stranger pushing/pulling off furniture
Stranger approaches on furniture
Stranger disturbs while resting/sleeping
v 3-2-2015
 None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  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 14 of 28
What is your pet’s response to: (cont)
Stranger approaches while eating
Stranger touches while eating
Strange takes pet food away
Stranger takes water dish away
Stranger takes rawhide
Strange hugging the pet
Stranger kissing the pet
Stranger lifting the pet
Stranger calling off furniture
Stranger pushing/pulling off furniture
Stranger approaches on furniture
Stranger disturbs while resting/sleeping
Stranger approaches while eating
Stranger touches while eating
Stranger takes pet food away
Stranger takes water dish away
Stranger takes rawhide
Stranger takes biscuit/cookie
Stranger takes real bone
Stranger approaches when pet has any
object/toy/bone
Stranger verbally punishes
Stranger poses visual threat, i.e., stare, wave
arms at pet
Stranger speaks to pet in normal tone
Stranger stares at pet
Stranger bends over pet
Stranger pushes on shoulders or back
Stranger approaches pet near spouse
Stranger enters room
v 3-2-2015
 None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  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 15 of 28
What is your pet’s response to: (cont)
Stranger leaves room
Stranger reaches toward pet
Stranger uses leash restraint
Stranger uses collar restraint
Stranger uses scruff restraint
Stranger takes leash off/on
Stranger puts collar on/off
Stranger bathes pet
Stranger towels pet
Stranger grooms/brushes pet
Pet at groomer’s
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 pet on
leash
Stranger child approaches owner and pet on
leash
Response to strangers when off leash
Pet at veterinary clinic
Pet in car, sees people/animals at tollbooths,
gas stations
Pet in house, sees people/animals outside
Response on leash to other pets
Response off leash to other pets.
v 3-2-2015
 None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  Growl Snap
Frequency:  +/ Intensity:  + /  None  Snarl  Hiss  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
Page 16 of 28
Characteristics of Aggressive Episodes
Attacks are sudden and surprising.
Episodes appear unprovoked.
Pet is abruptly docile afterward.
Pet appears “sorry” afterward.
Episodes associated with “glazed” or “absent”
expression.
I can usually tell what will set off my pet.
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 pet exhibit periodic diarrhea or
gastrointestinal distress?
Episodes of Human-Directed Aggression
If your pet bit when young, at what age?
Describe the first time your pet growled at a
person. At what age?
 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.
0
 Yes
1
 No
2
3
If so, describe:
 4-5
 6-7
 8-9
 >10
4
5
 >5
Describe the first time your pet snapped or bit
at a person. At what age?
If your pet has bitten a human, total number of
bites?
Does your pet bite more than once per
episode?
1
Pre-Bite
(air bite)
Human Bite Levels
2
Near Bite
(tooth
contact, no
puncture)
3
Shallow
Bite
(less than
depth of
canine
tooth)
4
Deep Bite
(depth of
canine
tooth)
5
6
Multiple
LifeBites
threatening
(deep and
(flesh
multiple) consumed
or victim
death)
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?
v 3-2-2015
 Yes
 No
If so, describe:
Page 17 of 28
Episodes of Pet-Directed Aggression
If your pet has bitten another pet, total
number of bites?
Bite Levels
Number of bites by severity?
How many bites to pets were reported?
To whom were they reported, i.e., local
authorities, hospital, human society?
Was legal action taken?
v 3-2-2015
0
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)
 Yes
 No
 >5
5
6
Multiple
LifeBites
threatening
(deep and
(flesh
multiple) consumed
or victim
death)
If so, describe:
Page 18 of 28
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 – Hissing, 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 – Hissing, 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
 Salivate  Defecate  Urinate
 Always (>95%)  No reaction
 Escape  Pant
 Pace
 Frequently
 Don’t know
 Hide
 Tremble  Destroy
 Occasionally
Thunderstorms
 Freeze  Won’t eat  Pupils dilate  Rarely
 Vocalize (Hiss, whine, growl, howl)
 Never
Does your pet react to other aspects of
storms?
Fireworks
Gunshots/backfires
Mechanics, i.e., vacuums, blowers, etc.
v 3-2-2015
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 (Hiss, whine, growl, howl)
 Never
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (Hiss, 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 (Hiss, whine, growl, howl)
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
Page 19 of 28
Reactions to Noise (cont)
Siren/alarms
Cars/trucks
How frequently do noise events occur in the
pet’s environment?
Has this pet 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 (Hiss, whine, growl, howl)
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (Hiss, 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 20 of 28
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 pet - guard, hunting, etc.
Specific Approaches
Stare at or “stare down”
Grab by jowls and shake
Get a companion pet for this one
Step on leash or choke collar and force down
Blow in nose or face
Provide different types of pet 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
Electronic or shock collar by trainer
v 3-2-2015
Screen is used to evaluate the role previous treatment recommendations
may play in your pet’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
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
Page 21 of 28
Specific Approaches (cont)
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 pet with hand
Blow torch
Hit pet with empty plastic soda bottle
Hit pet with whiffle ball bat
Hit pet with leash
Hit pet with chain
Hit pet with board, plank or baseball bat
Hit pet under chin
Step on pet’s toes
Knee pet in chest/belly
Kick pet
Bite pet
“Alpha roll” (hold spread-eagle on back)
“Dominance down” (hold down on side, legs
extended, head flat)
Growl at pet
Yell or scream at pet
Long down
Sit and wait
“Time out” (where, how and for how long)
Praise for good behavior
Crate
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 22 of 28
Specific Approaches (cont)
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 pet’s nose/face into urine, feces or
destruction
Use scat mats or other electronic avoidance
systems
Calming cap
Thundershirt or Anxiety Wrap
Other:
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 23 of 28
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 pet respond to its name or seem
aware of the surroundings while in the midst of
the behavior?
Is the pet aware that you are calling him/her?
Can you convince the pet 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 pet 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 pet’s general changed in any way since
the onset of the atypical behavior, i.e., the pet
is more or less aloof, aggressive, withdrawn,
playful, etc.?
Has the pet’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 pet 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 hissing  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 24 of 28
Patterns of Repetitive Behavior (cont)
Did any other pet in the pet’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 25 of 28
AGE-ASSOCIATED BEHAVIOR SCREEN
Locomotory/Ambulatory
Appetite
Elimination
Visual Acuity
v 3-2-2015
*
Complete ONLY if you have a pet 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
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.
Page 26 of 28
AGE-ASSOCIATED BEHAVIOR SCREEN (cont)
Auditory Acuity
Interactions
Sleep/Wake Cycle
Check only one –
 No apparent change in auditory acuity.
 Some decrease in hearing – not responding to sounds the pet used to
 Extreme decrease in hearing – have to make sure the pet is paying
attention, repeat signals, go get the pet 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.
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 pet.
Is a pedigree available?
 There is a pedigree available for this pet 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 pets may lick
themselves whereas others follow fences or
chase their tails. If you know what other
affected pets do, describe.
v 3-2-2015
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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 pet.
 The problem is very serious and I’d like to change it and, it if remains unchanged, I’ll euthanize or give up my pet.
If considering rehoming or euthanasia, have you discussed this within the family? With the place where you obtained your pet?
Is there anything else you think we should know?
COMMENTS
Attachments
Floor plan for each residence.
Primary vet medical
Primary vet laboratory results esp CBC, UA, chem screen, T4 (if ever done)
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