Owner Details

Name *

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Have you owned a dog before?

Yes
No

Have you owned this breed of dog before?

Yes
No

Have you owned other pets previously?

Yes
No

Please list other current household pets:

Type and Breed

Name and Age

Neutered or Entire

Relationship with other pets (e.g. plays, avoids, fights)

Please list the names, ages and occupations of other family members who live at home:

Name

Age

Occupation

Patient Details

Name *

Breed *

Age/Date of Birth *

Weight (kg) *

Sex *

Male
Neutered Male
Female
Speyed Female

Date first obtained

Where obtained

Age when obtained

Reason for obtaining this dog

Has the dog ever been used for breeding?

Yes
No

How would you describe your dog's personality?

The Current Problem

What is the current problem you are having with your dog?

When did it begin?

How long has it been present?

How old was the dog when it began?

Where does the problem occur?

With whom?

How often?

Aggression

Please answer the questions below if the problem is aggression.

Describe the most recent incident and the setting it occurred in (please try to be very precise, as if you were drawing a picture).

Where was the dog?

Where was everyone in relation to the dog?

What was everyone doing before the incident?

What did the dog do?

What was the dog's body posture? Describe the position of ears, tail, face, hair on back, or draw a picture if necessary.

Please upload a picture or drawing here, if available.

Drag & Drop Files, Choose Files to Upload

What was your reaction to the behaviour?

How did the dog react to your reaction?

Was there any punishment?

If there was a bite wound, was it a puncture wound or a tear?

Going back in time, describe the three most recent incidents of the behaviour.

How frequently does the problem occur?

Times per day

Times per week

Times per month

Times per year

When do the problems occur?

When left alone?

Always
Usually
Rarely
Never

When family members are present?

Always
Usually
Rarely
Never

What has been done to correct the problem?

Over time is the problem getting...

Better
Worse
No change

Do you suspect any cause?

Medical History

Please give a brief medical history, especially recurrent problems and treatment.

Vaccination status

Date last wormed

Is your dog currently on any regular medications such as allergy or arthritis medication, heartworm treatment, herbal or homeopathic remedies?

Drug/Remedy

Dose

Has your dog been on medication for his/her behaviour in the past? If Yes, please list name and dosage of medications, including herbals and homeopathics.

Drug/Remedy

Dose

Is your dog on any medication for his/her behaviour now? If Yes, please list name and dosage of medications, including herbals and homeopathics.

Drug/Remedy

Dose

Early History

Please give details of the dog’s early life, if known, including litter size, age of weaning, age when obtained, whether raised outside or indoors, of orphan or stray, whether hand-reared, etc.

How much interaction did the puppy have with people in the first year of its life?

What method of house training was used?

How did you react to any mistakes during house training?

Did your puppy attend puppy 'parties' or classes? If so, please give details.

Training and Obedience

Has your dog ever attended training classes?

Yes
No

What types of training techniques were used in the class?

How well did you dog do in the class?

Very well
Average
Poor
Was asked to leave

Do you think your dog is Good, Average or Poor at learning?

Good
Average
Poor

Does your dog do 'tricks' such as shake or rollover? If so, please describe.

Does your dog pull when on the lead?

Yes
No

Is your dog more obedient in some places than in others?

Yes
No

Is your dog more obedient with some people than with others?

Yes
No

How do you correct your dog when he/she misbehaves?

Daily Activities

Diet and Feeding

What types of food (including brands) do you give your dog?

How much does he/she eat a day?

When and where is the dog fed?

Who feeds the dog?

Is your dog protective around food? (stiffening, growling, snapping or biting?)

Yes
No

Is his/her appetite good or poor?

Good
Poor

Does your dog eat quickly or slowly?

Quickly
Slowly

What are his/her favourite foods?

Do you have to be present for him/her to eat?

Yes
No

How much does your dog drink each day?

Do you add supplements or tidbits to the diet?

Yes
No

Sleeping and Waking

Where does your dog sleep?

If your dog sleeps on the bed, who invites him/her up?

When does your dog get up in the morning?

Does your dog ever wake you at night?

Yes
No

Going Outside

When does your dog go outside and for how long?

How does your dog ask to go outside?

Does he/she roam free in a garden or yard?

What type of fencing is used to restrain your dog?

Is your dog keen to explore when on his/her own?

Toileting

Where does your dog tend to go to the toilet?

Does your dog spot mark with small amounts of urine?

Yes
No

How often does your dog empty its bladder in a day?

How frequently does it empty its bowels?

Exercise

What sort of exercise does your dog receive and how much? (e.g. walking on/off lead, agility training)

Type

Purpose

Amount

Frequency

Play / Training

Is there any specific time devoted to play and/or training on a daily basis?

Yes
No

Does your dog play games with you or other family members?

Yes
No

Who initiates play: people or the dog?

What types of toys does your dog play with?

Home Alone

Where does the dog stay during the day when no one is home?

What does he/she do as you prepare to depart?

Does your dog ever bark or whine when you leave?

Yes
No

Does your dog ever

Vocalise
Inappropriately toilet
Engage in destructive behaviour while you are gone?

Typically, how long is your dog alone without people on any given day?

Family Routine

What does your dog do during family meals?

Has there been a change in your household routine such as new work hours, new baby, moving, new household members, visitors, boarding, or diet change?

Yes
No

Favourite Things

Please list five things your dog enjoys most. These may be foods, toys, or activities.

Item 1

Item 2

Item 3

Item 4

Item 5

Interaction With Family Members

The Home Environment

What type of home do you have (e.g. flat, apartment, house)?

Reaction to Visitors

How does your pet behave when visitors come to the house (e.g. barking, door charging)?

Is the behaviour different towards familiar and unfamiliar people?

Is the behaviour different towards people outside the house and people inside the house?

Does your pet display aggression (growing, snarling, snapping, or biting) towards visitors to your home?

Has your dog ever bitten or attacked anyone?

Reactions to Other People

Please fill in details of any visitors to the home.

Individual (e.g. friend, tradesperson, postie)

Purpose

Time and days (e.g. frequent, occasional, rare visitors)

What is the reaction to other animals?

Other Behaviours

Does your dog ever show inappropriate mounting or other sexual activity?

Yes
No

Is your dog ever protective over parts of his/her body (especially ears and feet)?

Yes
No

Does your dog lick or chew on themselves more than you would expect?

Yes
No

House Soiling

If the current problem is house soiling, does it take place...

When you are not present?

Yes
No

When someone is home?

Yes
No

Destruction

If the current problem is destruction, does it take place...

When you are not present?

Yes
No

When you are at home?

Yes
No

You and Your Dog

How would you describe your relationship with this dog?

Adult owners (female)

Adult owners (male)

Children

What are your feelings about the dog's present behaviour?

Adult owners (female)

Adult owners (male)

Children

Under what circumstances would you consider euthanasia?

What is your expectation for change?

Is there anything else you would like to add about your dog and its behaviour?

Please give any other information you think is relevant to this case.

Questionnaire completed by:

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Canine Behaviour Consultation Questionnaire