Phone: (302) 322-6488 Fax: (302) 322-7666
www.animalvetcenter.com
Dr. James Berg
Dr. Renee Boggs Dr. Roberta
Jackson Dr. Teri Shultz
Canine Behavior
History Form
Date of Last Physical Exam: ________ Weight (lb): ________
ATTENTION CLIENT:
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 information
Client Name: _____________________________ Email: ________________________
Home Phone: ______________ Work: ______________ Cell: ______________
Additional Name on Account: _______________________ Phone: ______________
Patient Information
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Pet Name |
Species |
Sex |
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Date of Birth |
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Breed |
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Color |
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Canine
Feline |
Male / Neutered
Female / Spayed |
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If your pet
is neutered, at what age was he/she neutered? ___________
Behavior Information
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?
IV. Education
16. Method of house breaking? Age when house broken?
17. Does the animal ever eliminate in the house
now?
18. Who trained the animal? How well does the animal obey for each
person?
Please use chart: good, fair, poor
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Person |
Sit |
Down |
Come |
Stay |
Heel |
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19. Does the animal obey better in certain places?
20. Other obedience training (CD, CDX, etc.)
21. Any tricks such as fetch, shake hands?
22. Hunting or harness training?
23. How does your dog act during storms?
24. How does your dog act when it is left alone?
V. Feeding
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 mounts, does he/she mount
dogs (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?
VII. Grooming
30. Does the animal keep its coat in good
condition? Are there any areas which are
licked excessively?
31. Does the animal tolerate brushing or enjoy it?
VIII. Social
32. Is the animal
aggressive or timid with other animals of the same species? With
other species?
33. How does the animal act with:
Friends:
Children:
Strangers:
Veterinarians:
34. a. When does the dog bark?
b. When does the dog whine?
IX. Learning
35. Would you describe your pet as a good, fair,
or poor learner?
X. Sleep
36. Does the animal sleep through the night? Is he restless at night? Where does the
animal sleep at night?
XI. Medical
37. Brief medical history.
38. Describe a typical day in the dog’s life.