BEHAVIOR MODIFICATION CONSULTATION QUESTIONNAIRE Date* Date Format: MM slash DD slash YYYY How Did You Hear About UsGoogleFacebookFlyer/AdvertisementName* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Email* Dog's InformationDog's NameDog's WeightDog's Date Of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleNeutered/SpayedYesNoAge Neutered/SpayedBreed or Mix (if Known)ColorWhere Did You Obtain the PetBreederShelterRescueGiftAge ObtainedFor What Purpose Was Your Pet Obtained?Behaviour of Parents or LittermatesThe Home EnvironmentType of FoodHow Often is Your Dog Fed?Type of Treats?How Often Do You Give Treats?When Do You Give Treats?List any SupplementsList All Other Pets, Including Species, Breed, Age, and SexDescribe how your pets get along with each other:List each family member living in the home (include gender and age of children):Describe briefly how your dog gets along with each family member including any problems:DAILY ACTIVITIES AND ROUTINEType of exercise/play:Who exercises/plays?How often/how long?Where is your dog’s favorite sleeping spot?Where does the dog sleep at night?Have you ever used a crate for confinement?NoYesIf yes, please describe the crate and locationDescribe the dog’s reaction to being crated?Do you still use a crate?NoYesIf no, when and why did you stop?Briefly describe the usual daily schedule for the family:TRAININGHas this dog had any training?YesNoIf yes, please choose all that apply Class Private Instructor I Trained on My Own Describe training classes your dog has had (including trainer’s name if applicable):Type of training collar used (choose all that apply) None (trained off leash) Choke chain Prong collar E collar (shock collar) Head halter Harness How would you describe the training (choose one)?Reward-basedAssertive/domineeringAversive/mostly correctionsWas the training successful?YesNoIs there any ongoing training?YesNoPUNISHMENTHave you ever used any of the following for punishment or training? Physical punishment (hitting, kicking) Noise punishment (shaker can/siren) Ultrasonic Water sprayer Verbal reprimands Physical handling (muzzle grasp) Pinning (“alpha roll”) Time-out Booby traps/repellants What punishment is most effective?Do any of the punishments make the problem worse?YesNoIf yes, please describe:HANDLINGAre you able to handle your dog for: (check all that apply) Nail trimming Brushing Rubbing belly Grabbing collar Rolling over Hugging/kissing Ear cleaning Bathing Patting head Being lifted Teeth brushing Giving medications HOUSETRAINING(please complete this section if you require assistance with housetraining your dog)Is your dog completely housetrained?YesNoIf No, please continue to answer the following questions Does your dog ever eliminate outdoors?YesNoIf No, please continue to answer the following questions Do you accompany your dog to its elimination site?YesNoWhat do you do after your dog eliminates in the correct location?What do you do when you catch your dog soiling in an incorrect location?Does your dog signal to eliminate?YesNoIf yes, describe:About how often does your dog house soil?When is the dog most likely to house soil?Does your dog soil in the home byUrinatingDefecatingBothWhat are the most likely locations for indoor elimination?Does your dog house soil when family members are at home?YesNoDoes your dog house soil while you are watching?YesNoIf yes, describeWhat do you do when you find urine or stool in the improper location?Does your dog urine mark?YesNoIf yes, describe:Does your dog ever eliminate in a location where he/she has been sleeping?YesNoDoes your dog ever leak/dribble urine?YesNoDo you ever confine your dog to a crate?YesNoIf yes, does your dog ever eliminate in the crate?YesNoUncontrollable urination when excited?YesNoUncontrollable urination when frightened?YesNoDoes urine leak while your dog is: sleeping walking approached by owners approached by stranger (choose all that apply) MEDICALAppetite:NormalEats fastPickyEats slowly(Choose one) Dog’s Body Condition:ThinIdealHeavyObeseMuscularDoes your pet have any arthritis or other painful conditionsYesNoIf yes, please describeHave you noticed any deficits in your pet’s senses?YesNoIf yes, please describeDoes your pet have any other medical problems?YesNoIf yes, please describeIs your pet presently on any medicationYesNoIf yes, include name, dosage, and duration:HOME ALONE BEHAVIOURWhen you go out is your dogconfinedcratedallowed the run of the houseIf confined, please indicate in what area/restrictionHow long is the dog left alone on the average day?At what time of the day is your dog left alone?How does your dog react when you prepare to leave?Is the dog ever alone outdoors?YesNoIf yes, How often? How long (average)?Where is the dog left when outdoors?How does your dog react to being left alone outdoors?Does your dog exhibit any behavior problems when left alone?YesNo(If No, please skip ahead to next section) If Yes, please continue to answer the following questions Describe your dog’s behavior when left alone at home(list problems and how long after departure they occur): How does your dog react at the time of departure (as the last person prepares to leave)?Does the behavior differ depending on who is the last to leave?What is the dog’s reaction at homecomings?Have you ever left the dog alone in the car?YesNoIf yes, what is their reaction?REACTIVITYindicate how your dog reacts to each of the following (check all that apply) Familiar dogs on property: Calm Excited Ambivalent Fearful Friendly Aggressive Familiar dogs off property: Calm Excited Ambivalent Fearful Friendly Aggressive New dogs on property: Calm Excited Ambivalent Fearful Friendly Aggressive New dogs off property: Calm Excited Ambivalent Fearful Friendly Aggressive Strangers outside on property: Calm Excited Ambivalent Fearful Friendly Aggressive Strangers off property: Calm Excited Ambivalent Fearful Friendly Aggressive Strangers arriving indoors: Calm Excited Ambivalent Fearful Friendly Aggressive Car rides: Calm Excited Ambivalent Fearful Friendly Aggressive Thunderstorms/fireworks: Calm Excited Ambivalent Fearful Friendly Aggressive Other loud noises (e.g., shouting): Calm Excited Ambivalent Fearful Friendly Aggressive AGGRESSION SCREEN(Please complete this section if there have been signs of aggression (growling, bite attempts, biting) Does your dog display: Threatening displaysYesNoGrowling?YesNoBite attempts?YesNoBites?YesNoWhen was the most recent attempt to bite or threaten?Petting/handling/restraint Growl Attempted Bite Bite Situations causing aggression (check all that apply)Eating food or treats Growl Attempted Bite Bite Situations causing aggression (check all that apply)Chewing toys/stolen objects Growl Attempted Bite Bite Situations causing aggression (check all that apply)Waking up Growl Attempted Bite Bite Situations causing aggression (check all that apply)What is the potential for injury (choose one):none/preventableminimalmoderatesevereIs your dog aggressive to members of the immediate family?YesNoIf yes, please describeIs your dog aggressive to visitors to your home?KnownStrangersBothIs your dog aggressive to people when off property?KnownStrangersBothIs there a particular person or type (age, sex, uniforms) that your dog is most likely to threaten or bite?YesNoIf yes, please describe:Is there a particular location or situation where aggression is most likely to occur?YesNoIf yes, please describe:Has your dog ever bitten hard enough to break skin or cause injury?YesNoIf yes, please describe:Describe situations where your dog barks, threatens, or growls, but does not bite:Does your dog ever display aggression to other animals?YesNoIf yes, what animals, and describe the aggressionWhen your dog threatens or attempts to bite, how do you handle the situation and what is the dog’s reaction?After your dog has bitten how do you handle the situation and what is the dog’s reaction?PRIMARY COMPLAINTWhat is the primary problem? (aggressive, destructive, house soiling, barking, etc.):How would you describe the severity of this problemMildModerateSevere(choose one) Have you seen a veterinarian for this problem?YesNoIf yes, what treatments/protocols were recommended? Were they successful?Have you considered euthanasia for this problem?YesNoComment:When did the problem begin?What do you think caused the problem?Describe the problem, beginning with the most recent incident:Describe previous incidents:Describe the first incident:How often does the problem occur?Has there been a recent change in frequency or severity?YesNoIf yes, please describe:Describe any changes in the home or the pet’s health when the problem first started:What has been done so far to try and correct the problem?What has been the dog’s response?List any techniques that have been at all successful:List any techniques that have made the problem worse:List any drugs tried so far, and the dog’s response to medication:List any other dietary treatments, supplements, or remedies and the dog’s response:MISCELLANEOUS(please choose all that apply) Jumps up on owners Jumps up on strangers Won’t come when called Nips/grabs with mouth Only listens when feels like it Pushy/demanding Noise sensitivity On furniture where not allowed Phobic/excessive fear/panic In rooms where not permitted (please choose all that apply) Food stealing Eats non-food items (pica) Licks objects Destructive Chewing Digging Activity:NormalLazy/inactiveRestless/won’t settleHighly activeOveractiveGrooming:Normal groomingExcessive grooming/lickingSelf-injurious grooming/lickingRepetitive/compulsive/unusual activity:Tail chasingSuckingStar gazingFly chasingLight ChasingChasingStaringIf Chasing Please DescribeHunting/predationYesNoIf yes, please describe:Vocalization: Barking Howling Whining Shyness/timidityYesNo(non-aggressive), e.g., ears back, cowering, tail tucked, shaking, retreating, hiding, etc. Consent* I agree to the privacy policy/Terms and ConditionsCAPTCHA
