ANIMAL BEHAVIOR CLINIC
NEW PATIENT HISTORY, Canine
Ver: 10/07
Date: ___________ Owner's Name: ___________________________________ Person Filling out this form: ________________________
Dog's Name: _______________________Hair coat (lng, med, shrt): _______ Color: ___________ Breed: ____________________________
Age: _____ yrs.__ ___ mos. Wt: ____ Sex(M/F): ____ Neutered(Y/N): ____ At what age: ____ Comment: ________________________
Age acquired: ________ From (shelter, breeder, friend, etc.): ___________________________
Why did you acquire this pet? (companion, breeding, etc.)
IN THE ORDER THAT THEY ARRIVED IN YOUR HOME, please list ALL (including this pet) non-caged pets in your home.
NAME
BREED
SEX
AGE
OBTAINED
AGE
NOW
HOW DOES THIS PET RELATE TO THE OTHERS?
1)
2)
3)
4)
5)
Please list each human household member (please include sex, age, and daily schedule):
1)____________________ M/F Age: _____ Schedule:______________________________________________________________________
2)____________________ M/F Age: _____ Schedule: _____________________________________________________________________
3)____________________ M/F Age: _____ Schedule: _____________________________________________________________________
4)____________________ M/F Age: _____ Schedule: _____________________________________________________________________ 5)____________________ M/F Age:
_____ Schedule: _____________________________________________________________________
Which of these does most of the: feeding: ____________________ exercising: _____________________ playing:____________________
grooming: __________________ disciplining: _____________________ And which is the dog's best friend ______________________
Are any of these humans new to the home since the dog arrived? Which and when?
Have primary owners lived with dogs before? Have primary owners raised a dog before? Details please.
Our family life (even if it is just you and your pet) is:
Extremely organized ___, organized ___, unstructured ___, disorganized ___, chaotic ___.
All members of the household like or tolerate this dog except:
All members of the household are somewhat to highly motivated to change this dog except (details please):
Your home is: APARTMENT/CONDO (1BR) (2+ BR), DUPLEX, SINGLE HOME, TRAILER, FARM, OTHER ________________
Hours per day
your dog spends OUTSIDE:
SUPERVISED: (on leash _____) (off leash _____) UNSUPERVISED: (running free ______) (fenced in _______) (chained _______)
Number of hours your dog(s) are alone on average work day? _____ Where is dog(s) kept when alone?
Dog(s) reaction to your departure:
Dog(s) activities when left alone:
Dog(s) reaction to your return:
Dog(s) reaction to physical punishment:
Dog(s) reaction to car rides:
Page 2
DIAGRAM OF YARD and/or HOME (2)
(As they relate to the dog's behavior problems)
Please include:
1) Fences, runs or chains
2) Buildings, including access doors to yard.
3) The highest elevation that the dog may reach outside (including decks, furniture, etc.)
4) Where the dog likes to watch from inside of yard or home to streets, sidewalks, neighbors, etc.
5) If barking is a problem, indicate spot(s) where he/she barks.
6) The dog's favorite resting place(s), or any spot the dog considers to be HIS/HERS.
7) Any other behavior problem spots.
Please "highlight" any areas where behavior problems take place.
***<<< IMPORTANT! >>>***
Please describe YOUR PET'S daily routine on a separate sheet or on the back of this page.
Page 3
House training method: Results: (3)
Are there any current house training problems? Please give details:
Main Diet: _____ % canned; _____ % dry; _____ % table Meals per day: _______ Favorite brands if any?
Snacks/treats: How many in 24 hours? What kind? When?
How many rawhides or "chewies" does your dog get per week?
How often brushed/combed at home? ___________________ Dog's reaction:
Sleeps where?
Obedience training? _____ At what age? _____ Group or private lessons? _____ Do-it-yourself? _____ Results:
Training was: primarily LEASH ORIENTED? Primarily FOOD TREAT ORIENTED? A balance of EACH?
How was your dog taught to HEEL?
Please circle the commands that your pet will respond to reasonably reliably:
HEEL COME SIT SIT STAY DOWN DOWN STAY OFF NO FREE (or some other release command)
Other than COME, what commands do you use in everyday life?
In what circumstances do they work the best?
WHEN
and HOW does your dog show fear?
How often does this happen?
Have you ever used a cage for confinement? Do you still use a cage? Size/type of cage:
Is the cage used for punishment? Details please:
Please describe your dog's response to being caged:
Does your dog chew, scratch your home or furnishings? Y / N Under what circumstances?
How do you deal with that?
Has your pet ever had:
___ convulsion ___ reaction to medication ___ severe ear infection ___ excessive grooming
___ fainting spells ___ diagnosis of allergy ___ arthritis ___ eating problem
___ nervousness ___ depression ___ other painful problem ___ head injury
Other serious illness or accident? Please give details (use back of form if necessary):
Is your pet presently on any medication? _____ Please give details:
Please describe your pet's basic personality:
My dog is (circle all that apply):
intelligent * spiteful * shy * touchy * affectionate * sensitive * playful * grumpy * curious * fearful
hyperactive * basically nice * basically nasty * aloof * confident * aggressive to family * psychotic
aggressive to strangers * excessively defensive * difficult to handle * aggressive in play * defiant
My dog growls in anger: never ____ rarely ____ sometimes ____ often ____
Does your dog have a spot (chair, hallway, bed, etc.) that he/she guards as his/her own? Y / N Please describe:
Page (4)
Does your dog lick, chew, or suck a particular area of his/her body more than you would expect? Y / N If yes, please give details:
Does your dog do certain behaviors exactly the same way, repeatedly, and / or to a degree that you correct him/her? Y / N Details, please:
Under what circumstances does your dog bark or howl excessively?
How do you deal with this?
I (or other member(s) of my family):
Talk to my dog: a lot _____ often _____ sometimes _____ occasionally _____ rarely _____
Stroke (pet) my dog: a lot _____ often _____ sometimes _____ occasionally _____ rarely _____
The most important thing that Dr. Cameron should know about my pet and me is:
What is the prime reason you brought your pet to the Animal Behavior Clinic?
Please list any other behavior problems your dog may have.
BEHAVIOR PROBLEM
Previous diagnosis/treatment for the prime problem? (Please give details of when, who, what, etc.)
What do YOU think has caused this problem?
Have you considered euthanasia? Y/N Comment:
Have you moved since acquiring this dog? _______ How many times _______
At what age did you notice the FIRST symptoms of the main problem? About what date was that?
Please describe the first, or an early, incident:
Please describe changes in dog's environment shortly before problem started (move, redecorated, schedule, etc.):
Page (5)
Please describe how the problem changed after you first noticed it.
VERY
SERIOUS
SERIOUS
NOT
SERIOUS
In what situations is your dog most likely to misbehave?
How often does this happen (times per day, week, month)?
Is this main problem changing in degree or frequency? (Please give details.)
How do you most often deal with the situation when your dog does this behavior?
Some common behavior problems. Please check any that apply to your dog.
___ house soils ___ jumps up ___ aggressive ___ runs away ___ over sexed ___ sees things not there
___ disobedient ___ over active ___ bites ___ chews ___ eats stool ___ chases own tail
___ barks ___ damages home ___ fights ___ defiant ___ eats dirt ___ licks self excessively
Does your dog:
Paw at family members? Y N Guests? Y N Wear a path in yard from walking or running? Y N
Lick family members? Y N Guests? Y N Guard (aggressively protect) toys, food, chewies, other? Y N
Mount family members? Y N Guests? Y N Run in circles or spin repeatedly? Y N
Bark at family members? Y N Guests? Y N Eat unusual items at every chance? Y N
Have trance-like events? Y N Stare at things that do not seem to be there? Y N
Other bizarre behavior? (Please describe)
Page (6)
Dog's reaction to:
your giving a pill:
stranger at the door:
stranger while on walk:
veterinary office:
strange dogs:
thunder storms, loud noises:
spanking or other physical punishment:
other stress (please describe):
Where is your dog when you have guests?
Where is your dog when things are relaxed and quiet in the evening (you are watching TV, reading, etc.)?
Play usually consists of:
Type of discipline or control usually used when:
Excessive barking:
Nipping/biting:
House soiling:
House damaging (chewing):
Unruly:
Other:
My dog will not let me:
My dog is happiest when:
My dog is angriest (or most upset) when:
*<<< IMPORTANT! >>>*
Please describe: 1) the MOST SIGNIFICANT EVENT, and 2) the LAST EVENT typical of your dog's problem, IN DETAIL, on
the back of this page (or if faxing, just add another page to the fax). This is very important.
Please give as much detail as possible
.
Please mail the completed forms to: Dr. D.B. Cameron, 15353 N. Bloomfield Road, Nevada City, CA 95959
Or fax to 530.265.3103 (If faxing, please call first to clear the line.)