Behaviour History Questionnaire
General Information:
Full Name
*
First Name
Last Name
Preferred dates or times?
Address
Postal Code
Email
*
Home Phone
Work Phone
How Did You Hear About Us?
Vet & Clinic name
Training Information:
Location for Training
In Home
Chinook
Killarney
What concerns would you like help with?
Does your dog show signs of fear and/or reactivity with dogs or people?
Yes
No
If yes, please describe. Did it cause injury?
Pet Information:
Dog's Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2004
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2002
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Sex
Male
Female
Spayed/Neutered?
Yes
No
Breed
Colour
Briefly describe your dog’s personality (e.g. quiet, confident, excitable, unruly, bold, stubborn etc.)
Does your dog have any medical concerns?
The Home Environment
Type of Food?
Type of treat(s)?
List any supplements/medications:
List all other pets, including species, breed, age, and sex:
Describe how your pets get along with each other:
List each family member living in the home (include sex and age of children):
Describe briefly how your pet gets along with each family member including any problems:
Describe typical daily exercise/play:
Is your dog crate trained?
Yes
No
Have you ever used any other form of confinement (e.g. baby gate or x-pen, etc.)?
Training
Has this pet had any obedience training?
Yes
No
If so, what sort of training have they had?
Class
Private instructor
I trained my pet at home
Describe training classes your dog has had (included trainers name or training school name):
How does your dog react to being left home alone?
Check off types of training collar's used:
None, trained off leash
Neck Collar
Remote Collar (e.g. shock. citronella, etc)
Head halter
Body Harness
Please use a scale of 1 (poor) to 5 (excellent) to indicate how your dog responds below:
Sit:
Sit-Stay:
Down:
Down-Stay:
Loose Leash Walking:
Come:
Leave It:
Give/Drop It:
Go to Bed/Mat:
Sit to greet people:
Miscellaneous
Disobedient?
Yes
No
Please select if any of the following apply to your dog:
Jumps up (owners)
Jumps up (strangers)
Won’t come when called
Nips/grabs with mouth
Only listens when feels like it
Pushy/demanding
On furniture where not allowed
In rooms where not permitted
Destructive chewing or digging:
Yes
No
If yes to either, describe:
Hunting/Predation:
Yes
No
Mounting other dogs, or people:
Yes
No
If yes to any of the above, describe:
Vocalization:
Barking
Howling
Whining
If yes, describe:
Anxiety/fear?
Yes
No
Noise sensitivity?
Yes
No
Phobic/excessive fear/panic?
Yes
No
If answered yes to any of the previous questions, describe:
Shyness/timidity (non-aggressive) e.g. ears back, cowering, tail tucked, shaking, retreating, hiding, etc.
Yes
No
If yes, describe any situations not discussed previously where your dog is fearful or overly anxious:
How long after exposure to these events does your dog settle down (i.e.,back to normal)?
Additional problems or comments:
Submit
Should be Empty: