Behavior Service
Canine History
The information you provide below will be used during your
consultation to develop a diagnosis and plan of treatment.
Please fill it out as completely as you can. All information will be held in strict confidence and
will not be released to any third party without your written consent.
Please return at least 2 business days prior to your dog’s appointment by fax, mail, or email
to
Email: [email protected]
Fax: 248.354.0303
Mail: Jill Sackman, DVM, PhD
BluePearl Veterinary Partners
29080 Inkster Road
Southfield, MI 48034
Today’s Date: Click here to enter a date.
Your Contact Information
Your name: Click here to enter text.
Phone numbers:
(home) Click here to enter text.
(work) Click here to enter text.
(cell) Click here to enter text.
(fax) Click here to enter text.
Address: Click here to enter text.
Email: Click here to enter text.
Your Family Veterinarian’s Contact Information
Family Veterinarian: Click here to enter text.
Hospital Name: Click here to enter text.
Hospital Address: Click here to enter text.
Veterinarian’s Phone Number: Click here to enter text.
BluePearl Veterinary Partners Behavior Service
Canine History Form -- Page 1 of 11
Your Dog’s Information
Dog’s Name: Click here to enter text.
Spayed or Castrated? ☐ No ☐ Yes
Breed: Click here to enter text.
Age at which spayed or castrated: Click here
Dog’s Birthdate: Click here to enter a date.
Sex: ☐ Male ☐ Female
to enter text.
Weight: Click here to enter text.
Color: Click here to enter text.
Had behavior training? ☐ No ☐ Yes
How old was our dog when you acquired him/her? Click here to enter text.
Where did you acquire your dog (i.e. breeder, shelter, friend, etc.)? Click here to enter text.
Behavior History
What is the main Behavioral Problem or complaint?
Click here to enter text.
How Serious would you rank this behavior?
☐ Very serious ☐ Serious ☐ Not serious
How often does this behavior occur?
☐ Daily ☐ Weekly ☐ Monthly
Please describe in detail the most recent incident:
Date of Occurrence: Click here to enter text..
Please give a detailed description of occurrence: Click here to enter text.
Please describe in detail the very first incident you remember:
Date of Occurrence: Click here to enter text..
Please give a detailed description of occurrence: Click here to enter text.
How old was your dog when he/she first began showing signs of this behavior? Click here to
enter text.
BluePearl Veterinary Partners Behavior Service
Canine History Form -- Page 2 of 11
How long has the behavior been going on?
Days: Click here to enter text.
Months: Click here to enter text.
Years: Click here to enter text.
Has there been any change in the frequency of the problem behavior or the way it is exhibited?
Click here to enter text.
When did this behavior become a serious concern?
Click here to enter text.
How do you discipline your dog for this problem or other misbehavior?
Click here to enter text.
What steps have already been taken to solve the problem?
Click here to enter text.
What will you do if this behavior cannot be corrected?
Click here to enter text.
Are there any other behavior problems? Please list:
Click here to enter text.
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Canine History Form -- Page 3 of 11
What is your goal for this consultation? What would you like to see accomplished?
Click here to enter text.
Medical History
Please describe any medical problems that this dog has had previously or currently has:
Click here to enter text.
Is your dog currently on any medication or special diet? Please list all and include heartworm
prevention and flea medications.
Click here to enter text.
Please list all vaccines and dates given within the last year:
Click here to enter text.
Your Dog’s Environment
Please describe all of the people living in the household now, starting with yourself:
First Name
Sex
Age
On a scale of 1-10, describe the
relationship with the dog.
1= hate 10=love
Relationship
(spouse, son, etc.)
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SELF
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Canine History Form -- Page 4 of 11
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What is the type of area in which you live? ☐ City/Town ☐ Suburban ☐ Rural
What type of home do you live in? ☐ Apartment ☐ Duplex ☐ Single Family ☐ Farm
Has the household changed since the dog was acquired? ☐ No ☐ Yes, please describe (such as
addition of family member, addition of pet, move, etc.): Click here to enter text.
How many times have you moved with the dog since acquiring him/her? Click here to enter text.
Were there previous owners of this dog?
☐ No
☐ Yes; if yes, how many? Click here to enter text. Reason for giving up dog? Click here to
enter text.
Diet and Feeding
Feeding
Type(s) of food consumed: ☐ Canned ☐ Moist ☐ Dry ☐ Human Food
Brand of food Click here to enter text.
Supplements/snacks? Click here to enter text.
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Canine History Form -- Page 5 of 11
Has there been a recent diet change?
☐ No
☐ Yes
If yes, from what and when? Click here to
enter text.
When is your dog fed (please list times)? Click here to enter text.
Where is your dog fed? Click here to enter text.
Who feeds your dog? Click here to enter text.
Is your dog offered any treats? Click here to enter text.
What kind of treats? Click here to enter text.
Please describe your dog’s appetite ☐ Normal ☐ Excessive ☐ Poor
Water
Where is the water bowl located? Click here to enter text.
Water intake: ☐ Normal ☐ Excessive ☐ Poor
Other
Does this dog ever steal food from counters? ☐ No ☐ Yes
…from garbage? ☐ No ☐ Yes
Your Dog’s Daily Routine
Sleeping
Where does your dog sleep? Click here to enter text.
Does your dog sleep all night long? Click here to enter text.
Daytime
Where your dog spends time during the day: Click here to enter text.
Hours indoors: Click here to enter text.. Hours outdoors: Click here to enter text.
If outdoors: ☐ on leash ☐ pen ☐ free roaming
If you have a fence for our dog, is it an invisible/underground fence or a physical fence?
☐ No fence ☐ Invisible/underground ☐ physical fence, how tall? Click here to
enter text.
Is the dog allowed on the furniture in the house? If so, what? Click here to enter text.
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Canine History Form -- Page 6 of 11
Are there any areas of the house which are off-limits to the dog? Click here to enter text.
Exercise
Type(s) of exercise: Click here to enter text.
How many hours per day? Click here to enter text.
How many hours per week? Click here to enter text.
With which family members? Click here to enter text.
What is your dog’s activity level in general?
☐ Low ☐ Average ☐ High ☐ Excessive
List the types of toys your dog has and indicate which toys are preferred or are your
dog’s favorites:
Click here to enter text.
Please list other activities you currently engage in with your dog:
Click here to enter text.
Other Animals
List all animals in the household in the order they were acquired, including pets who have died
within the last year:
Name
Species
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Breed
Sex
Age
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Canine History Form -- Page 7 of 11
Indoor or
outdoor?
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Please describe relationships between above pets and dog being evaluated:
Click here to enter text.
These pets groom the dog in question: Click here to enter text.
These pets eat with the dog in question: Click here to enter text.
These pets play with the dog in question: Click here to enter text.
These pets fight with the dog in question: Click here to enter text.
Does your dog play with other pets outside the family? If so, please describe.
Click here to enter text.
Has your dog ever bitten another animal? If so, please describe:
Click here to enter text.
Please describe other pertinent relationships:
Click here to enter text.
Training
☐ No☐ Yes; age when housetrained: Click
Is the dog housetrained?
here to enter text.
Has your dog ever been crate trained?
☐ No ☐ Yes
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Canine History Form -- Page 8 of 11
Has your dog attended obedience classes?
☐ No
☐ Yes, if yes:
Age when attended: Click here to enter text.
Where and what trainer? Click here to enter text.
Family members who attended obedience class with dog: Click here to enter text.
Please describe dog’s interaction with other people at class: Click here to enter text.
Please describe dog’s interaction with other animals at class: Click here to enter text.
What percent of the time does your dog obey the following cues/commands for each family
member?
Family
Member
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Stay
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Come
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Heel/Don’t
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Your Dog’s Interaction with People
Has this dog ever bitten anyone (adult or child)?
☐ No ☐ Yes: if yes, what were the circumstances? Click here to enter text.
Does your dog behave when you leave home? Click here to enter text.
How does your dog greet you when you return home (e.g. jump on you, run in circles, hide, wag
tail, etc.)? Click here to enter text.
Is this dog afraid of any adults, children, objects, loud noises, etc.?
☐ No ☐ Yes; if yes, please describe: Click here to enter text.
BluePearl Veterinary Partners Behavior Service
Canine History Form -- Page 9 of 11
Does your dog like to be held by family members?
☐ No ☐ Yes: if yes, by whom? Click here to enter text.
Does your dog liked to be brushed or groomed?
☐ No ☐ Yes; if yes, by whom? Click here to enter text.
For the following behaviors, please check one or more of the boxes under these descriptions:
NR = no reaction
B = bark in a threatening manner
SL = snarl/rumble with teeth showing (mouth
open or closed)
BT = bite, teeth close rapidly and contact
person (may/may not leave mark)
M = mutter/grumble with mouth closed
G = growl with mouth closed, no teeth
showing
SN = snapping, teeth close rapidly without
contacting person
ND = never done
***IMPORTANT*** IF YOU HAVE NEVER DONE SOME OF THESE TASKS, DO NOT TRY THEM***
What is your dog’s response when you or a family member does the following?
Type of Behavior
Take dog’s meal away while he/she is eating
Add food to bowl while dog is eating
Take away dog’s favorite toy
Pet the dog
Trim dog’s nails
Lift or try to lift dog
Grab dog by collar
Hug or kiss dog
Scold dog verbally
Bend over dog
Push on dog’s back
Bathe dog
Reach toward dog
Wake dog when sleeping
Unfamiliar adult enters yard or house
Unfamiliar child enters yard or house
Familiar adult enters yard or house
Familiar child enters yard or house
Response to toddlers/babies
NR
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Canine History Form -- Page 10 of 11
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Dog in car at gas station/drive thrus
Unfamiliar adult approaches dog on leash
Unfamiliar child approaches dog on leash
Response to other dogs on leash
Response to other dogs off leash
Dog in house sees people outside
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Please add any other information you feel is pertinent:
Click here to enter text.
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Canine History Form -- Page 11 of 11
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