BEHAVIOR MODIFICATION CONSULTATION QUESTIONNAIRE Date* MM slash DD slash YYYY How Did You Hear About Us Google Facebook Flyer/Advertisement Name* 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 Name Dog's Weight Dog's Date Of Birth MM slash DD slash YYYY Sex Male Female Neutered/Spayed Yes No Age Neutered/Spayed Breed or Mix (if Known) Color Where Did You Obtain the Pet Breeder Shelter Rescue Gift Age Obtained For What Purpose Was Your Pet Obtained? Behaviour of Parents or Littermates The Home EnvironmentType of Food How Often is Your Dog Fed? Type of Treats? How Often Do You Give Treats? When Do You Give Treats? List any Supplements 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 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? No Yes If yes, please describe the crate and location Describe the dog’s reaction to being crated? Do you still use a crate? No Yes If no, when and why did you stop? Briefly describe the usual daily schedule for the family: TRAININGHas this dog had any training? Yes No If 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-based Assertive/domineering Aversive/mostly corrections Was the training successful? Yes No Is there any ongoing training? Yes No PUNISHMENTHave 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? Yes No If 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? Yes No If No, please continue to answer the following questions Does your dog ever eliminate outdoors? Yes No If No, please continue to answer the following questions Do you accompany your dog to its elimination site? Yes No What 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? Yes No If 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 by Urinating Defecating Both What are the most likely locations for indoor elimination? Does your dog house soil when family members are at home? Yes No Does your dog house soil while you are watching? Yes No If yes, describe What do you do when you find urine or stool in the improper location? Does your dog urine mark? Yes No If yes, describe: Does your dog ever eliminate in a location where he/she has been sleeping? Yes No Does your dog ever leak/dribble urine? Yes No Do you ever confine your dog to a crate? Yes No If yes, does your dog ever eliminate in the crate? Yes No Uncontrollable urination when excited? Yes No Uncontrollable urination when frightened? Yes No Does urine leak while your dog is: sleeping walking approached by owners approached by stranger (choose all that apply) MEDICALAppetite: Normal Eats fast Picky Eats slowly (Choose one) Dog’s Body Condition: Thin Ideal Heavy Obese Muscular Does your pet have any arthritis or other painful conditions Yes No If yes, please describe Have you noticed any deficits in your pet’s senses? Yes No If yes, please describe Does your pet have any other medical problems? Yes No If yes, please describe Is your pet presently on any medication Yes No If yes, include name, dosage, and duration: HOME ALONE BEHAVIOURWhen you go out is your dog confined crated allowed the run of the house If confined, please indicate in what area/restriction How 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? Yes No If 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? Yes No (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? Yes No If 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 displays Yes No Growling? Yes No Bite attempts? Yes No Bites? Yes No When 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/preventable minimal moderate severe Is your dog aggressive to members of the immediate family? Yes No If yes, please describe Is your dog aggressive to visitors to your home? Known Strangers Both Is your dog aggressive to people when off property? Known Strangers Both Is there a particular person or type (age, sex, uniforms) that your dog is most likely to threaten or bite? Yes No If yes, please describe: Is there a particular location or situation where aggression is most likely to occur? Yes No If yes, please describe: Has your dog ever bitten hard enough to break skin or cause injury? Yes No If 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? Yes No If yes, what animals, and describe the aggression When 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 problem Mild Moderate Severe (choose one) Have you seen a veterinarian for this problem? Yes No If yes, what treatments/protocols were recommended? Were they successful?Have you considered euthanasia for this problem? Yes No Comment: 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? Yes No If 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: Normal Lazy/inactive Restless/won’t settle Highly active Overactive Grooming: Normal grooming Excessive grooming/licking Self-injurious grooming/licking Repetitive/compulsive/unusual activity: Tail chasing Sucking Star gazing Fly chasing Light Chasing Chasing Staring If Chasing Please Describe Hunting/predation Yes No If yes, please describe: Vocalization: Barking Howling Whining Shyness/timidity Yes No (non-aggressive), e.g., ears back, cowering, tail tucked, shaking, retreating, hiding, etc. Consent* I agree to the privacy policy/Terms and ConditionsCAPTCHA Δ
