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If your pet has a behavior appointment, please fill out this form...
Phone: (302) 322-6488 Fax: (302) 322-7666
Dr. James Berg Dr. Renee Boggs Dr. Teri Shultz
Canine/Feline Behavior History Form
Date of Last Physical Exam: ________ Weight (lb): ________
Please complete this form with as much detail as possible and return it to us before your appointment. You may fax, drop off, or send it by standard mail to AVC Behavior Service at the above address. Please send fax replies or drop off at least 2-4 days prior to the appointment and standard mail at least 7-10 days prior to the appointment. If we do not receive your completed form 24 hours prior to your appointment your appointment will be canceled. Please call at least 24 hours in advance to cancel or change your appointment. If you do not call in advance to cancel or change your appointment, you will be billed for half the price of the consultation. Please videotape your pet performing the behavior(s) before your visit, if possible. Please drop off the video 48 hours prior to your appointment so it can be reviewed. Thank you and we look forward to working with you and your pet(s)!
Client Name: _____________________________ Email: ________________________
Home Phone: ______________ Work: ______________ Cell: ______________
Additional Name on Account: _______________________ Phone: ______________
If your pet is neutered, at what age was he/she neutered? ___________
I. Chief Complaint
1. What is the main behavior problem or chief complaint?
2. When did the problem begin?
3. When does the animal misbehave? How often and under what circumstances?
4. Has there been a change in frequency or appearance of the problem?
5. What has been done so far to correct the problem?
6. a. Describe the first incident?
b. Describe the most recent incident?
c. Describe the next most recent incident?
d. Other incidents?
7. Are there any other behavior problems?
II. Animal's Environment
8. What persons are in the animal's environment? What are their schedules?
9. What other animals are in the house or on the premises?
10. Where is the animal kept during the day? At night? When owner is away?
11. How is the animal exercised? Does it run free? How and when do you play with it?
III. Early History
12. Why was the animal obtained?
13. Source of the animal?
14. Age at weaning?
15. Age when obtained by present owner?
16. Method of house breaking? Age when house broken?
17. Does the animal ever eliminate in the house now?
18. For Dog. Who trained the animal? How well does the animal obey for each person?
Please use chart: good, fair, poor
19. (Dog)Does the animal obey better in certain places?
20. (dog)Other obedience training (CD, CDX, etc.)
21. (dog)Any tricks such as fetch, shake hands?
22. (dog)Hunting or harness training?
23. How does your dog/cat act during storms?
24. How does your dog/cat act when it is left alone?
25. What is the animal fed and when is it fed?
26. Who feeds the animal? Can you take the food away from the animal?
27. Does it have a good appetite? Does it like treats?
VI. Sexual and Maternal
28. Has the animal shown mounting behavior (male or female) or has it been in heat?
If the dog/cat mounts, does he/she mount dogs/cats (sex?) or inanimate objects (e.g. pillows)?
29. Has the animal been bred or used for breeding? Was it a good mother? Does the
animal ever "mother" toys or other animals?
30. Does the animal keep its coat in good condition? Are there any areas which are
31. Does the animal tolerate brushing or enjoy it?
32. Is the animal aggressive or timid with other animals of the same species? With
33. How does the animal act with:
34. For dogs only
a. When does the dog bark?
b. When does the dog whine?
35. Would you describe your pet as a good, fair, or poor learner?
36. Does the animal sleep through the night? Is he restless at night? Where does the
animal sleep at night?
37. Brief medical history.
38. Describe a typical day in the dog's/cat's life.