Kat, behaviour tech

Canine Questionnaire

Please fill out the entire form to the best of your ability, prior to your consult with Kat, Behaviour Tech. All sections marked with * are required.

General History

Your name

Phone

Address

City, Province, Postal Code

Family veterinarian/clinic

Pet’s name

Pet’s breed

Pet’s date of birth/approximate age

Sex

Male intact Female intact Male neutered Female spayed

How old was your pet when you brought them home?

Where did you acquire your pet?

Describe the previous home (impressions of littermates, parents, foster home, etc):

What is your primary concern?

Home Environment

List all family members living in the home along with the ages of any children:

List any pets in the home along with ages:

Are there any children who regularly interact with your pet?

Yes No

Does your pet get along with everyone in the household (including other pets)?

Yes No

If no, please describe:

What type of food do you feed your pet?

What type of treats do you give your pet?

What is your favourite thing to do with your pet?

What are three things you love about your pet?

How would you describe your pet’s personality?

Primary Concern

When did this issue start?

How would you describe the severity?

Mild Moderate Severe

Have there been any changes in the home or the pet’s health since the primary problem started?

What do you think caused this problem?

Describe the most recent incident:

Describe the first incident and any other pertinent incidents:

How often does this problem occur?

What have you tried to improve this problem?

Has anything made the problem worse? Better?

Please list any other problems that need to be addressed along with how old your pet was when it started and the severity:

What are your goals for this consult?

Training History

Have you previously attended training with your dog?

Yes No

If yes, who was the instructor?

What behaviours does your dog know? (Ex. Sit, come, stay, etc.)

Was it easy to train your dog?

Describe what it’s like walking with your dog:

What do you use to walk your dog (leash, collar, harness, etc.):

How does your dog respond to handling? (nail trims, ear cleaning, baths, petting, picking up, giving medication, etc.)

Does your dog have any significant fears?

Is your dog afraid of thunder? Fireworks? Car rides? Any locations/situations?

Yes No

If yes to any, describe:

Is your dog housetrained?

Yes No

Do they every have accidents? When?

How does your dog react to being alone?

Have you ever recorded your dog while they’re alone?

Yes No

Has your dog ever caused sufficient injury to require medical attention?

Yes No

List all of the targets for the aggression (people/animals):

How many times has your dog bitten?

Health Status

When was your dog’s last veterinary visit?

Are vaccines up to date?

Yes No

Does your dog have any ongoing medical problems?

Is your dog on any medications or supplements?

Have you noticed any other health issues?

Not sure if I can help?

Send me an email with a brief description of your concern. I’ll be the first to tell you if you need the help of a different professional.

KAT, BEHAVIOUR TECH