Canine Behaviour Consultation Questionnaire
FORM CANCELLED:
May 13, 2022
CANCELLED
- This form has been cancelled.
Brunker Road Veterinary Centre
278 Brunker Rd
Adamstown NSW 2289 AU
02 4957 2269
info@brunkerroadvets.com.au
EMAIL
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Canine Behaviour Consultation Questionnaire
Behavioural problems are a common concern for pet owners and can greatly impact the human-animal bond. Particularly with behavioural problems, early detection is essential to achieving the best outcomes. There are a number of strategies we can prescribe to help you reach the best outcomes for you and your pet. Please complete all sections of this questionnaire to help us best understand your pet's health needs.
CLIENT DETAILS
First name
*
Last name
*
Email
*
Phone
Address
Pet Information
Animal name
*
Animal breed
*
Animal gender (e.g. male, female, unknown)
*
Select
Female
Male
Unknown
Animal DoB or age
*
Animal weight
*
Animal microchip
*
Where did you obtain this pet?
Describe previous home/homes (if known):
For what purpose was your pet obtained?
Behavior of parents or littermates (if known):
General Information
For referred cases: Veterinarian's name & clinic:
The home environment
Type of food:
How often is your pet fed?
When fed?
Type of treats?
How often do you give treats?
When do you give treats?
List any supplements:
Select the type of home you live in
Unit / apartment
Townhouse
House with no backyard
House with small backyard
House with large backyard
Acreage
List all other pets, including species, breed, age and sex:
Describe how your pets get along with each other
Principal Complaint
What is the primary problem? (aggressive, destructive, housesoiling, barking, etc.):
How would you describe the severity of this problem?
Mild
Moderate
Severe
Have you considered euthanasia? Y/N Comment:
Please answer all of the following unless they have been entirely covered in another section
Describe previous incidents:
Describe the first incident:
How often does the problem occur?
Has there been a recent change in frequency or severity? Y/N If yes, describe:
Describe any changes in the home or the pets health when the problem first started:
What has been done so far to try and correct the problem?
What has been the dogs response?
List any techniques that have been at all successful:
List any techniques that have made the problem worse:
List any drugs (include dosage) tried so far, and the dogs response to medication:
List any other dietary treatments, supplements, or remedies and the dogs response:
REINFORCER ASSESSMENT
What is your dogs favorite reward?
If you could give your dog ANY food as a reward, what would be the favorite? List the top five:
Other than food, what rewards (e.g., toy, affection) would be most enticing to your dog? List the top five:
DAILY ACTIVITIES AND ROUTINE
Type of exercise/play:
Who exercises/plays?
How often/how long?
Favorite game(s):
Favorite toy(s):
Where is your dogs favored sleeping spot?
Where does the dog sleep at night?
Have you ever used a crate for confinement? Y/N If yes, describe crate and location
Describe the dogs reaction to being crated?
Do you still use a crate? Y/N If no, when and why did you stop?
Briefly describe the usual daily schedule for the family:
TRAINING
Has this pet had obedience training? Please select all training types
Class
Private instructor
I trained my pet at home
Describe training classes your dog has had (including trainers name if applicable):
Dogs response for following questions, please rate: Success rate 15; 1 = poor, 5 = good
Type of training collar used
None, trained off leash
Neck collar Y/N If yes, indicate type:
Remote collar Y/N If yes, indicate type, i.e., shock, citronella, etc.
Head halter Y/N If yes, indicate type:
Body harness Y/N If yes, indicate type:
Briefly describe the training techniques:
What training was most successful?
What training was least successful?
Describe your dogs learning ability:
Is there any ongoing training? Y/N If yes, describe:
List family member(s) with most control:
List family member(s) with least control:
For each of the following use a scale of 1 (poor) to 5 (excellent) to indicate how your dog responds:
1. Sit:
Sit-stay 1 minute:
Sit-stay 5 minutes:
Sit-stay 10 minutes:
2. Down:
Down-stay 1 minute:
Down-stay 5 minutes:
Down-stay 10 minutes:
3. Come (indoors):
Come (in yard):
Come (in park):
4. Heel with no distractions:
Heel with distractions:
5. Give/drop:
Does your dog know any tricks? Y/N List/explain:
Can you get your dog to settle on command? Y/N If yes, describe:
PUNISHMENT
Have you ever used any of the following for punishment or training?
1. Physical punishment: Y/N Dogs reaction:
2. Noise punishment (shaker can/siren): Y/N Dogs reaction:
3. Ultrasonic: Y/N Dogs reaction:
4. Water sprayer: Y/N Dogs reaction:
5. Verbal reprimands: Y/N Dogs reaction:
6. Physical handling: Muzzle grasp: Y/N Dogs reaction:
Physical handling: Pinning: Y/N Dogs reaction:
7. Time-out: Y/N Dogs reaction:
8. Booby traps/repellants: Y/N Dogs reaction:
What punishment is most effective?
Does any punishment make the problem worse? Y/N If yes, describe:
Has punishment ever led to threatening behavior or aggression? Y/N Explain:
Does your dog respond differently to punishment from different family members? Y/N If yes, describe:
MEDICAL SCREEN
Appetite
Normal
Voracious
Decreased
Picky
Increased
Eats fast
Does your pet have any arthritis or other painful conditions? Y/N If yes, describe:
Have you noticed any deficits in your pets senses? Y/N If yes, describe:
Does your pet drink or urinate excessively? Y/N If yes, describe:
Stools: Please select all that apply
Normal
Constipation
Less frequent
More frequent
Soft/diarrhea
Urine: Please select all that apply
Normal
Infrequent
More frequent
More volume
Does your pet have normal eating and bowel movements? Y/N If no, describe:
Does your pet have any other medical problems? Y/N If yes, describe:
Is your pet presently on any medication? Y/N If yes, describe (include name, dosage, duration):
Has your pet had any laboratory tests (blood, urine, X-rays, etc.)? Y/N If yes, indicate any abnormal findings:
When you go out is your dog confined or crated? Y/N If yes, indicate if crated or what areas are restricted:
How long is the dog left alone on the average day?
At what time of the day is your dog left alone?
How does your dog react when you prepare to leave?
Has your dog ever been left at a kennel, veterinary hospital, or with a friend/relative?
If yes, describe your dogs reaction:
Is the dog ever alone outdoors? Y/N
How often?
How long (average)?
Where is the dog left when outdoors?
Does your dog exhibit any behavior problems when you leave it alone? Y/N
If No, proceed to Reactivity section - If Yes, please continue to answer the following questions:
Does the behavior differ depending on length of time or time of day left alone?
How does your dog react at the time of departure (as the last person prepares to leave)?
Does the behavior differ depending on who is the last to leave?
What is the dogs reaction at homecomings?
Have you ever left the dog alone in the car? Y/N If yes, how does it react?
REACTIVITY
Familiar dogs off property
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
Familiar dogs on property
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
New dogs on property
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
New dogs off property
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
Strangers outside on property
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
Strangers off property
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
Strangers arriving indoors
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
Car rides
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
Thunderstorms/fireworks
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
Other loud noises (e.g. shouting)
Calm
Excited
Ambivalent
Fearful
Friendly
Aggressive
AGGRESSION SCREEN
Has your pet ever displayed threats? Y/N
Has your pet ever displayed growling? Y/N
Has your pet ever displayed bite attempts? Y/N
Has your pet ever bitten anyone? Y/N
When was the most recent attempt to bite or threaten?
Petting/handling/restraint
Growled
Attempted to bite
Bitten
No aggression
If Yes, please describe
Eating food or treats
Growled
Attempted to bite
Bitten
No aggression
If Yes, please describe
Chewing toys/stolen objects
Growled
Attempted to bite
Bitten
No aggression
If Yes, please describe
Waking up
Growled
Attempted to bite
Bitten
No aggression
If Yes, please describe
Is aggression the primary reason for today's visit? Y/N
What is the potential for injury?
None/preventable
Minimal
Moderate
Severe
Is the problem serious enough that you will be unable to keep your pet if it is not improved? Y/N
Is your dog ever aggressive to members of the immediate family? Y/N
If Yes, please describe
Is your dog ever aggressive to visitors to your home? Y/N
Were the people known, strangers, or both?
Describe your dogs behavior when left alone at home (list problems and how long after departure they occur):
Were the people known, strangers, or both?
Is there a particular person or type(age,sex,uniforms) that your dog is most likely to threaten or bite?
is there a particular location or situation where aggression is most likely to occur?
Has your dog ever bitten hard enough to break skin or cause injury? Y/N
If Yes, please describe
Describe situations where your dog barks, threatens, or growls, but does not bite
Does your dog ever display aggression to other animals? Y/N
If Yes, what animals?
Describe aggression
When your dog threatens or attempts to bite, how do you handle the situation and what is the dog's reaction?
After your dog has bitten how to you handle the situation and what is the dog's reaction?
How would you describe your dog's attitude at the time of the aggression? (bold, protective, outgoing, fearful, etc.)
How would you describe your dog's expression and postures at the time of aggression? (cowering, ears back, tail tucked, hackles raised, retreating, hiding)
AMENDMENT
Amendment Description *
Update estimate *
I, the undersigned, acknowledge that I have read and understood this amendment, which has been fully explained to me, and that it modifies the original consent form to which it is attached. I confirm that all information provided is accurate and that I consent to the changes outlined in this amendment. I understand that this amendment is part of the original consent form.
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