University of Minnesota Veterinary Medical Center
Behavior Service
Margaret Duxbury DVM, DACVB
1365 Gortner Ave, St. Paul, MN 55108
Phone: 612-624-0797
Fax: 612-624-8779 Email: vetbehav@umn.edu
BEHAVIOR QUESTIONNAIRE COVER SHEET
Please complete the attached questionnaire and return it by mail, email or fax (see above) when you are
ready to schedule an appointment.
A credit card number is required to hold your appointment once it has been scheduled. Because a large
block of time is reserved for each appointment, we request the courtesy of 2 business days notice if you
need to cancel your appointment. If an appointment is cancelled less than 2 business days from the
appointment date or you do not show for the appointment, there is a cancellation fee of $180.00 that will
be charged to this credit card.
Helpful Hints for Veterinary Behavior Appointments
1. Appointments are typically 2-3 hours in length.
2. All persons who regularly interact with the pet should attend the appointment (for ages under 12
discuss when scheduling the appointment).
3. All pets currently involved in the problem behavior should attend the appointment.
4. Please send a video of your pet’s behavior to the address above so that it is received prior to the
scheduling of your appointment. If a video cannot be sent prior to your scheduling, please make
sure we receive it by your appointment time. Please do NOT provoke aggressive behavior in order
to make a videotape.
5. What to bring to the appointment
a. Your pet hungry; no food 12 hrs before the appointment but water is fine
b. Your pet’s favorite food or treats
c. Your pet’s favorite toy(s)
d. A log of your pet’s negative behavior for a minimum of 7 days prior to his/her appointment,
but longer is great.
Questions?
Call: 612-624-0797
Email: vetbehav@umn.edu
Page 1 of 11
Form adapted with permission from Florida Veterinary Behavior Service
University of Minnesota Veterinary Medical Center Behavior Service
Margaret Duxbury DVM, DACVB
CANINE QUESTIONNAIRE
OWNER INFORMATION
Owner name:
Address:
Daytime phone:
Alternate phone:
Email:
How did you find out about us?
Who is your pet’s primary care veterinarian?
Do you want us to be in contact with them?
If yes, Clinic name:
Y
N
Veterinarian’s Name:
PATIENT INFORMATION
Pet’s Name:
Breed:
Color:
Date of Birth or age:
Weight:
Sex:
lbs
M
Kg
F
Neutered/Spayed:
Y
N
Unknown
How old was your dog when neutered/spayed?
From where did you obtain your dog?
How old was your dog when you first acquired him/her?
Has this dog had other owners?
If yes, how many?
1
Y
N
Unknown
2
3
4
>4
Unknown
Why was the dog given up by the previous owners?
Do your dog’s parents or littermates have ANY known behavior problems or concerns?
If yes, what types of problems?
Page 2 of 11
Form adapted with permission from Florida Veterinary Behavior Service
Y
N
Unknown
BEHAVIORAL HISTORY
Please fill out the table below in regard to your dog’s primary behavior problems in order of concern.
Problem/concern
Age at which began and its historical development
Frequency
Nature of
problem
Daily
Very serious
Weekly
Serious
Monthly
Not serious
Yearly
Daily
Very serious
Weekly
Serious
Monthly
Not serious
Yearly
Daily
Very serious
Weekly
Serious
Monthly
Not serious
Yearly
Daily
Very serious
Weekly
Serious
Monthly
Not serious
Yearly
Please give a detailed description of significant representative events of each concern. Please include the location, dog’s
body postures, any people or animals present, any triggers, your reaction/response, and the final outcome.
Behavior concern:
Incident Date(s):
Description of the incident (s):
Behavior concern:
Incident Date(s):
Description of the incident(s):
Page 3 of 11
Form adapted with permission from Florida Veterinary Behavior Service
Behavior concern:
Incident Date(s):
Description of the incident(s):
Behavior concern:
Incident Date(s):
Description of the incident(s):
Have you considered finding another home for this dog due to unwanted behaviors?
Y
Have you considered euthanasia (putting your dog to sleep) due to unwanted behaviors?
N
Y
N
BITE HISTORY
To People:
If your dog has ever bitten/nipped anyone, please check the total number of bites/nips (teeth have touched skin):
0
1
2
3
4
5
>5
Please check the number of bites/nips to people that broke skin:
0
1
2
3
4
5
>5
Please check the number of bites/nips to people reported to public health authorities:
0
1
2
3
4
5
>5
Has there ever been a police report filed as a result of a bite/nip to a person?
Was there legal action taken against you as a result of the bite(s)?
Y
Y
N
Unknown
N
To Other Animals
If your dog has ever bitten/nipped at another animal, please check the total number of bites/nips (teeth have touched skin):
0
1
2
3
4
5
>5
Please check the number of bites/nips to other animals that broke skin:
0
1
2
3
4
5
>5
Please check the number of bites/nips to other animals reported to public health authorities:
0
1
2
3
4
5
>5
Has there ever been a police report filed as a result of a bite/nip to another animal?
Was there legal action taken against you as a result of the bite(s)?
Describe the most severe injury that has occurred from a bite?
Page 4 of 11
Form adapted with permission from Florida Veterinary Behavior Service
Y
N
Y
N
AGGRESSION HISTORY
For the questions below, aggression is defined as any of the following: growls, bares teeth, lunges, snaps or bites.
Who is your dog aggressive toward?
adults living in the home
adults not living in the home
veterinarian
other dog(s) living in the home
other dog(s) not living in the home
other household pets
children living in the home
Please give age(s) of children:
children not living in the home
Please give age(s) of children:
Is your dog aggressive when?
reached for
spoken to
corrected
touched
looked at
toweled dry
bathed
nails trimmed
in your bed
in his bed
pushed/pulled
given commands
picked up or lifted
leash/collar put on or taken off
hugged
playing with toys
sleeping
he has a bone
resting
if food drops on the floor
playing
eating/around food bowl
on walks
when startled
if he sees motorcycles/skateboards/bikes
he sees kids
examined at the veterinarian’s office
CONFINEMENT
Have you ever used a crate?
Y
If yes, do you continue to use it?
N
Y
N
If yes, when do you use it?
When your dog is confined to a crate, how does he/she react?
When your dog is confined away from you and you are home, how does he/she react?
Page 5 of 11
Form adapted with permission from Florida Veterinary Behavior Service
kissed
groomer
FEARS
Please check all reactions that apply.
Fireworks
Trembles
Tucks Tail
Hides
Escapes
Destroys
Urinates
Defecates
Barks/Whines
Tucks Tail
Hides
Escapes
Destroys
Urinates
Defecates
Barks/Whines
Tucks Tail
Hides
Escapes
Destroys
Urinates
Defecates
Barks/Whines
Thunderstorms
Trembles
Loud noises
Trembles
Please list any specific stimuli (i.e., men, umbrellas, traffic noises) your dog seems to be afraid of (write more than one on a line
if needed):
1.
2.
3.
4.
5.
6.
DIET AND FEEDING
What type and brand of food and treats do you feed your dog?
How many times a day do you feed your dog?
Do you feed in a specific location?
Y
1
2
3
Free choice
N
Please describe your feeding procedure for:
Meals:
Treats:
What is your dog’s eating habit(s) check all that apply?
very fast/gulps food does not chew
very slow/chews the kibble but stays at the food bowl the whole time
picks out kibble and goes elsewhere to eat it but finishes bowl
finicky/ picks at the food but never finishes it
won’t eat anything without you present
If other animals eat at the same time, describe the arrangement (e.g., same room, separate rooms, etc)?
Page 6 of 11
Form adapted with permission from Florida Veterinary Behavior Service
DEPARTURE BEHAVIOR
Do your dog’s behavior problems occur when you are leaving or not home?
Y
N
If yes, answer the questions below. If No, move to the next section.
How do you prepare to leave the house when the dog will be left alone?
How does your dog react?
How does your dog behave when you return?
What do you do when you return home after being gone for any period of time?
Where is your dog when you are not home?
Does your dog exhibit any of the following when left alone? (Mark all that apply)
Tremble
Hides
Won’t eat
Whines/cries
Attempts to Escape
Destroy
Urinate
Defecate
Bark
Drools
If you marked anything above; how soon after being left alone does the misbehavior begin?
Does the dog exhibit the behavior when one particular person leaves, but not another?
Y
N
Please name the person(s) that needs to leave:
Does your dog exhibit the behavior with every departure?
Y
N
If No, does it matter how many times you depart in a day before the behavior occurs?
How many departures must occur for the behavior to occur?
Does the dog exhibit the behavior only when he/she is alone?
Y
1
2
3
Y
N
4 or more
N
If there is another animal in the house does it matter if they are present in the home or not?
Y
N
At what point in your departure routine does your dog begin to exhibit signs of stress (panting, pacing, head down, following you)?
How long does it take for your dog to calm down when you return?
What techniques have you tried to alter your dog’s misbehavior when he/she is alone?
Page 7 of 11
Form adapted with permission from Florida Veterinary Behavior Service
PREVIOUS TREATMENTS
Before consulting with the U of MN Veterinary Medical Center Behavior Service, did you:
1. Consult a non-veterinary behavior consultant?
Y
N
If yes, please list name(s):
2. Consult your own veterinarian?
3. Consult a trainer?
Y
Y
N
N
If yes, please list name(s) of trainer:
4. Consult with others?
Y
N
If yes, please list name(s):
Please complete the table below and list all recommendations you received and how they worked
Who
Recommended
Recommendation(s)
Outcome
Which of the following have you tried or used to correct the undesired behavior? Check all that apply
stare down
hang by collar
scruff or shake by scruff
growl, bark at or bite the dog
choke collar
pinch/prong collar
head collar (Gentle Leader/Halti)
harness
crate
shock collar
citronella collar
muzzle
shake or throw can
loud noise
hit or slap with hand
hit or slap with another object
treats
knee/step on toes
Increase play
water pistol/spray bottle
dog sports
get another pet
praise
time out
remove food bowl while eating
increase exercise/play
decrease exercise/play
force/push onto side and hold
yelling
clicker
Page 8 of 11
Form adapted with permission from Florida Veterinary Behavior Service
What unwanted behavior(s) is the dog reprimanded for, how and how often?
Unwanted Behavior
Number of times
reprimanded
How reprimanded
Time per
day
month
week
year
day
month
week
year
day
month
week
year
day
month
week
year
day
month
week
year
HOME ENVIRONMENT
Please list the people, including yourself, living in your household. Include the age for children.
Name
Age
Relationship
Sex
Average # of hours away
from home per day
(i.e. self, spouse)
Quality of relationship
with dog
Please list all the animals in the household in the sequence they were obtained:
Name
Species
Breed
Sex
Neutered
or
Spayed?
Page 9 of 11
Form adapted with permission from Florida Veterinary Behavior Service
Age
obtained
Age now
Quality of relationship
with dog
What type of yard do you have?
Large (more than an acre)
What type of fence do you have (mark all that apply)?
Privacy fence
Open pickets
Medium (1/3 to 1 acre)
Small (less than 1/3 acre)
Unfenced
Underground/Electric fencing
Chain link
Post and rail
Other
DAILY SCHEDULE
Do you leash walk your dog?
Y
N
If yes, how many times per day?
How long are the walks? (please list time and length)
Does your dog have access to the outside through a dog door?
If yes, can your dog go in and out whenever they wish?
Y
N
Y
N
Y
N
Where is your dog when you have guests?
Describe your play sessions with your dog?
Does your dog play with any other dogs on a regular basis?
If yes, describe what those play session look and sound like?
Where does your dog sleep?
MEDICAL HISTORY
Please list current medication(s) that your pet is taking, include: prescription and non prescription (heartworm, flea
prevention and supplements), mg size of medication, dosage, when you are giving it and how are you giving it?
1.
2.
3.
4.
5.
6.
Page 10 of 11
Form adapted with permission from Florida Veterinary Behavior Service
Please list your pet’s current and previously diagnosed medical problems and how they were treated.
Date of illness
Treatment (include medication dosage and
dates/duration)
Condition
TRAINING
Have you ever taken your dog to training classes?
Y
N
What training classes have you taken your dog to and what was the age of dog when s/he was enrolled
puppy class
Age:
Trainer/school:
beginner obedience Age:
Trainer/school:
advanced obedience Age:
Trainer/school:
agility
Age:
Trainer/school:
fly ball
Age:
Trainer/school:
Other
Age:
Trainer/school:
Do you currently participate in any dog sports with your dog?
Y
N
If yes, please list them and how your dog is doing in the sport?
ELIMINATION BEHAVIOR
If your dog has accidents in the house, please fill out this section. If not, you are done.
Does your dog ever urinate or defecate in the house?
If yes, does s/he:
urinate
defecate
Y
N
both
How did you housetrain your dog? (Please describe in detail)
Page 11 of 11
Form adapted with permission from Florida Veterinary Behavior Service
Outcome