Canine Behavior Questionnaire Pet Parent InformationFirst and last name:(Required) Address:(Required) Primary phone number:(Required)Email:(Required) List all veterinary clinics your pet has visited in the past 5 years:Who referred you to the behavior service? Please list the names of anyone we have permission to speak with regarding your pet, including any family members who will not be present at the initial consultation. We may only discuss your pet with their primary care veterinarian, others require written authorization. Pet InformationPet name: Breed: Color: Date of birth/Age: Sex: Spayed/Neutered: Yes No Age of spay/neuter: Where and when did you get your dog? Has your dog had other (human) parents prior to living with you? Yes No Do you have information about your dog’s history before you acquired them? If so, please explain.What are your goals for this appointment?List any existing health issues your pet has, including allergies or sensitivities:What do you feed your pet? What do you love the most about your dog? Recent research has shown connections between gut health and brain health. Please mark how often your dog has any of the following signs:Vomiting Daily Weekly Monthly Occasionally Rarely Diarrhea Daily Weekly Monthly Occasionally Rarely Constipation Daily Weekly Monthly Occasionally Rarely Decreased appetite Daily Weekly Monthly Occasionally Rarely Excessive licking Daily Weekly Monthly Occasionally Rarely Lip licking Daily Weekly Monthly Occasionally Rarely Environmental InformationHow many adults are in the household?Are there any children, elderly members, or immunocompromised individuals in the household or who visit regularly? Yes No Check all that apply to your pet’s environment: Leash walked Fenced yard Tie out Electric fence Dog park How many play sessions does your dog get per day?List any other pets in the household and their relationship with the patient:Presenting ConcernsList the first concern for which you are seeking help: Age problem 1 started? Unknown Less than 4 months old 4 to 12 months old 1 to 3 years old 3 to 7 years old 7 years old or later Frequency of problem 1? Always Sometimes Rarely Never Has problem 1 gotten: Better Worse Unchanged Describe the most recent 2 incidents of this problem: List the second concern for which you are seeking help: Age problem 2 started? Unknown Less than 4 months old 4 to 12 months old 1 to 3 years old 3 to 7 years old 7 years old or later Frequency of problem 2? Always Sometimes Rarely Never Has problem 2 gotten: Better Worse Unchanged Describe the most recent 2 incidents of this problem: List the third concern for which you are seeking help: Age problem 3 started? Unknown Less than 4 months old 4 to 12 months old 1 to 3 years old 3 to 7 years old 7 years old or later Frequency of problem 3? Always Sometimes Rarely Never Has problem 3 gotten: Better Worse Unchanged Describe the most recent 2 incidents of this problem: Previous TreatmentsCheck all previous treatments that have been tried: Medications Supplements Avoidance Acupuncture Adaptil product CBD product Choke collar Citronella collar Clicker training Electronic collar Food toys (puzzle feeders, Kong) Hand feed/remove bowl while eating Hang by collar Head collar Hit or knee Hold down Increased play/exercise Loud noise (yelling, air horn, penny can) Muzzle No pull harness Obedience training Pressure wrap/Thundershirt Prong or pinch collar Stare down Time out Treats or food rewards Water pistol/bottle Other Other treatment: Have you and your dog ever worked with a dog training professional? Yes No List any dog training professionals you have worked with, including puppy classes. List any behaviors taught and what your dog knows well. Do you plan to continue working with the dog training professionals listed above? Yes No Sleep BehaviorsDoes your pet sleep through the night? Yes No Have there been any changes in your pet’s sleeping patterns in the past 3 months? Yes No Does your pet take naps during the day? Yes No Aggressive BehaviorsAggression describes a behavior, but it is not a personality trait. Aggressive behaviors include growling, lunging, biting, and some barking. If your dog has exhibited these behaviors in some situations, please answer the following section. If not, continue to the next section. These answers help your pet’s doctor appropriately diagnose and determine the best treatment plan for your dog. Has your pet ever bitten at a person (this includes an air snap)? Yes No Number of bites to a person: 1 2 3 4 5 or more Number of bites that broke skin: 1 2 3 4 5 or more Has your pet ever bitten at another dog (this includes an air snap)? Yes No Number of bites to a dog: 1 2 3 4 5 or more Number of bites that broke skin: 1 2 3 4 5 or more Has a bite ever been reported to public health authorities? Yes No Has there been any legal action regarding your dog’s behavior? Yes No When is your dog aggressive? Around food Baths Collar or leash put on/taken off Corrected/scolded Eating Examined by vet Grooming (professional) Grooming (family) Has bone/toy/chew Hugged In their bed In person’s bed In yard Nail trims On walks Playing Picked up Reached for Spoken to Touched Startled Woken up Other What other time is your dog aggressive? Who is your dog aggressive toward: Familiar adults Unfamiliar adults Familiar children Unfamiliar children Familiar dogs Unfamiliar dogs Visitors to home Other pets in household Other animals outside home Wild animals Check all that apply to your dog’s body language when they are aggressive: Bare teeth Bark Dilated pupils/glassy eyed Ears back Stiff body Growl Hair/hackles up Lip licking Lowered head Lowered body Lunge Pant Standing on hind limbs Tail above back Tail below back Tail tucked Tail wagging fast Tail wagging slow Turn head away Turn body away Try to escape Yawn Zone out Other Describe other body language when aggressive: Car BehaviorsIf your dog exhibits distress while riding in the car, please fill out the following section. If not, move on to Separation Behaviors.Check all that apply to your dog’s behavior when riding in the car: Bark Calm/relaxed/sleep Climb on person Defecate Drool Pace Pant Tremble Try to get to you Urinate Vomit Whine/cry Other What other behavior does your dog exhibit when riding in the car? Separation BehaviorsIf your pet exhibits distress when separated from you or left alone, please fill out the following section. If not, move on to Storms/Sound Behaviors.Where is your dog when you are not home? Behavior while you are gone or cannot be reached (check all that apply): Attempt to escape Bark Defecate Destructive Hide Howl Pace Pant Tremble Urinate Whine Other Other behavior while you are gone or cannot be reached: Behavior when you get ready to leave (check all that apply): Aggressive toward you Avoids going inside Avoids being confined Attempts to block you leaving Calm Hides Looks sad Follows you around Other Other behavior when you get ready to leave: Does your dog exhibit this/these behavior(s) every time they are alone? Yes No Does your dog exhibit this/these behavior(s) when a certain person departs, but not others? Yes No Behavior when you return home or dog can reach you (check all that apply): Calm, relaxed, or sleeping Bark/whine/jump for <1 min Bark/whine/jump for 1-2 mins Bark/whine/jump for <5 mins Bark/whine/jump for <10 mins Bark/whine/jump for <15 mins Bark/whine/jump for >15 mins Other Other behavior when you return home or dog can reach you: Describe anything else you would like to share about your pet’s behavior when you leave: Storms/Sound BehaviorsIf your pet exhibits fear or stress related to storms or noises, please fill out the following section. If not, move on to Veterinary Visits.What sounds cause your dog to exhibit fear or stress (check all that apply): Air brakes/large trucks Beeping Construction sounds Cooking sounds Diesel engines Doorbell Electronic alert sound Rain Thunder Other Other sounds that cause your dog to exhibit fear or stress? What is your pet’s body language in response to a scary sound (check all that apply): Aggressive when interacted with Bark Pace Pant Destructive Drool Find person/family member Howl Tremble Try to escape room or house Try to hide Other Other body language in response to a scary sound? How long does it take your dog to calm down after sound/storm ends? Calms down while still happening Immediately 5-10 mins 11-20 mins 21-30 mins 31-45 mins 46-60 mins 1-3 hours 4-6 hours 7-12 hours 12-24 hours More than 24 hours Veterinary Visit BehaviorCheck all that apply to your dog in the veterinary office and during examination: Tremble Cower Hide Try to escape Cry out Pace Pant Freeze Bark Growl Bare teeth Lunge Bite Check any other behaviors listed that your dog exhibits: Circling Snapping at air Chase tail Stare at lights/shadows Have euthanasia or rehoming been recommended or considered prior to your visit with us? Yes No Medical Records Please have your veterinarian and any specialists your pet has seen send us your pet’s medical records, including any lab work. Documents can be uploaded below or sent by email to petshrink@pazvet.com or by fax to 512-481-7071. The Day Of: Please schedule a consult for all pets that are involved in the problem if you can do so safely. If multiple pets are involved and only one pet can come to the appointment, then the doctor may recommend a consult for your other pet(s) to adequately treat the problem. Please bring your pet's favorite toys and treats with you to the appointment so that we can use those items during your pet's appointment, if appropriate. Photos and Videos Videos of problem behaviors may be helpful. Do not under any circumstance invite or trigger aggressive behavior for the purpose of a video. Please limit videos to 2 minutes or less so they can be quickly added to your pet’s medical record. File Uploads Drop files here or Select files Max. file size: 50 MB. Please be patient and allow all files to upload prior to continuing.If you provide a video or pictures of your pet(s), would you give us permission to use them for teaching purposes in textbooks, publications such as journals, and during teaching presentations? Yes No Each pet is an individual, so results of behavioral therapy cannot be guaranteed. While improvement can be seen quickly, many emotional disorders are chronic in nature and require continued therapy. Response to therapy is dependent on the individual’s response and the implementation of the recommendations made by your pet’s doctor. The behavior service is unable to guarantee that a treatment plan will be able to completely remove a patient’s aggression or potential danger to people or other animals. Pets should always be managed in accordance with local ordinances and leash laws.By signing below, I acknowledge that:I am the legal owner of the pet seeking behavioral medicine treatment from the behavior service at PAZ Veterinary. Follow up appointments for behavior therapies range from every 4 to 6 weeks to every few months depending on the case.Fees are to be paid at time of service and I accept responsibility for all charges that I approve related to the treatment of my pet. I am seeking treatment by the behavior service with full knowledge of the above and of the liability associated with ownership of a pet that has exhibited aggression in the past. Signature