Canine Behavioral History Form

The information you provide here is very important in identifying your dog’s behavioral issues and developing a behavior plan. Please fill out this form as completely and accurately as possible. We estimate that it will take about 20 minutes to complete the three pages.

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PART 1. BASIC INFORMATION

OWNER INFORMATION

First Name *

Last Name *

Email Address *

Phone Number *

Address *

Address Line 2

City *

State * ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code *

DOG INFORMATION

Dog’s Name *

Breed *

Sex * Select oneMale (intact)Male (neutered)Female (intact)Female (spayed)

Date of Birth (estimate if unknown) *

Current Age *

Age Obtained *

Current Weight *

Where did you obtain this dog? * Select onePet StoreBreederFriendAnimal ShelterRescueOther Where did you obtain this dog?

VETERINARY INFORMATION

Your primary veterinarian’s name

Name of clinic or hospital *

City *

State * ALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

PART II. PRINCIPAL BEHAVIORAL COMPLAINT

Summarize the primary behavioral problem in one sentence. *

How would you describe the severity of this problem? * Select oneMildModerateSevere

What is your primary goal in scheduling a behavior consultation? *

Have you considered rehoming? *

Yes

No

Have you considered euthanasia? *

Yes

No

Describe the last two incidents in as much detail as possible.

Date 1 *

Incident 1 *

Date 2

Incident 2

How many times has the problem occurred in the past week? *

How many times has the problem occurred in the past month? *

How many times has the problem occurred in the past year? *

If you are human, leave this field blank.

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