If your pet has a behavior appointment, please fill out this form...

Animal Veterinary Center

160 Bear-Christiana Road  Bear, DE 19701

Phone: (302) 322-6488    Fax: (302) 322-7666

www.animalvetcenter.com

Dr. James Berg     Dr. Renee Boggs     Dr. Teri Shultz

 

 

Canine/Feline 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

 

Pet Name

Species

Sex

 

Date of Birth

 

Breed

 

Color

 

Canine         Feline

Male / Neutered  Female / Spayed

 

 

 

 

 

 

 

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.  For Dog.  Who trained the animal?  How well does the animal obey for each person? 

        Please use chart: good, fair, poor

 

Person

Sit

Down

Come

Stay

Heel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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?

 

 

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/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?

 

 

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:

 

        Cats:

 

        Dogs:

 

 

34.  For dogs only

        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/cat's life.