Canine Behavior Questionnaire

Pet Name:*

Breed*

Color*

Pet Birthdate:*

Weight (if known)*

Sex:*

Female

Female, Spayed

Male

Male, Neutered

If spayed or neutered, at what age was the procedure?

If not neutered, reasons for not neutering (check all that apply):

Show dog

Plan to breed

Health concerns

Other

Date of last Rabies vaccination (specify 1-year or 3-year vaccine)*

People living in the household (include name, age, relationship)*

1.
2.
3.
4.
5.
6.

Other people in regular contact with the pet (e.g., pet sitters, housekeepers, relatives, friends, etc.). Please provide name, age, relationship.*

1.
2.
3.
4.
5.

Type of house:*

Single-family detached

Apartment

Attached/Townhouse

Mobile home

Other

Neighborhood:*

Urban

Suburban

Rural

Do you have a yard?*

Yes

No

If yes, how big is the yard?

Is the yard fenced?*

Yes

No

If yes, how high is the fence and what material is it made of?

Other pets in the household (in order they came into the household). Please provide name, species, breed, gender, age now & age when obtained.*

1.
2.
3.
4.
5.

How old was this dog when acquired?*

Where did you obtain this dog?*

Performance breeder (show, hunting, agility, etc.)

Hobby breeder

Private home/previous owner

Shelter/rescue organization

Pet store

Other

Behavior of dog's parents/littermates (if known):

Describe previous home(s) (if known):

Why did you acquire this dog? (check all that apply):*

Adult's pet

Family pet

Children's pet

Companion to other pet

Protection

Performance (show, hunting, agility, etc)

Breeding

Other

List any major illnesses/surgeries (dates):*

List ALL medications/treatments your dog is currently receiving, including heartworm, flea preventative, dietary supplements, and herbal/homeopathic treatments (provide name of medication, dosage/frequency given, and date started):*

1.
2.
3.
4.
5.
6.

When and where is the dog fed?*

Who feeds the dog?*

Types of food:*

Dry (brand and % of diet)
Canned (brand and % of diet)
Raw (ingredients and % of diet)
People's food (type and % of diet)
Treats (brand and % of diet)

Eating habits (check any that apply):

Eats right away

Picky eater

Anxious eater

Guards food from people

Guards food from dogs

Other

Where does your dog sleep at night?*

If disturbed while sleeping what is your dog's reaction (check all that apply)?*

Happy

Startled

Growls

Barks

Bites

Scared

Grumpy

Playful

Other

Does your dog get regular leash walks?*

Yes

No

If no, why?*

Does't walk well (pulls on leash)

Aggressive on walks

Don't have the time

Medical reasons

Other

If YES, who takes the dog for leash walks? How often and how long are the walks, and where do they occur?*

What do you use to walk the dog (check all that apply):*

Flat buckle collar

Body harness

Head collar (Halti, Gentle Leader)

Training/choke collar

Prong collar

Retractable leash

Long leash (6ft +)

Average leash (4-6ft)

Short leash (4ft or less)

Other

How is your dog on leash:*

Excellent (never pulls, pays attention to me)

Good (rarely pulls)

Fair (pulls, but I'm able to control)

Poor (pulls a lot, difficult to control)

Bad (pulls, I don't enjoy the walks)

Does your dog get off-leash exercise?*

Yes

No

If yes, who takes the dog for off-leash exercise? Where, how often, for how long?

Where does your dog spend the most time when people are home:*

Loose in the house w/no access to the outside

Loose in the house w/access to the outside

Confined (baby gates, etc.) to part of the house

Inside a crate or pen

Loose in the yard

Outside in a kennel or pen

Other

Where is your dog spend the most time when people are not home?

Loose in the house w/no access to the outside

Loose in the house w/access to the outside

Confined (baby gates, etc.) to part of the house

Inside a crate or pen

Loose in the yard

Outside in a kennel or pen

Other

How long is your dog left alone on an average day? Between what times?*

What is your dog's reaction to being left alone (check all that apply):*

Calm

Depressed

Barks

Cries/howls

Urinates/defecates

Escapes

Destructive

Anxious

Excited

Aggressive

Describe a typical 24-hour day in your dog's life, starting with when and where the dog wakes up in the morning. Include feeding, exercise, and play times. If behavior problems occur at particular times of the day, include that information.*

Has your dog had any training?*

No

Trained ourselves

Classes/Met with trainer

List type of classes, at what ages, and names of trainers:*

Puppy classes
Group classes
Private lessons
Board & train
Other

What training techniques or tools have you used (all that apply):*

Training collar (choke)

Food rewards

Verbal praise

Play/toys

Prong collar

Remote collar (citronella, shock, vibration)

Bark collars (shock, vibration, citronella)

Other

Who in the household trained the dog?

What commands does your dog know?*

Did your dog enjoy training?*

How well does your dog obey commands without distractions:*

Very well

Well

Fairly Well

Poorly

Does not follow commands

How well does your dog obey commands with distractions:*

Very well

Well

Fairly Well

Poorly

Does not follow commands

Does your dog engage in the following behaviors at least weekly?*

	No	When owner is present	When owner is gone	Don't know
House soiling
Excessive barking/whining
Destructive chewing
Digging
Self-licking/chewing
Pacing/repetitive behavior
Consuming non-food objects
Circling/chasing tail/freezing

How does your dog react to the following?*

	Happy & Relaxed	Excited/hard to calm (jumps)	Neutral	Fear/Anxiety/Submits	Snarl and/or Growl	Bark	Snap/Bite	Don't Know/Don't Do
Unfamiliar people at the door
Unfamiliar people in the home
Unfamiliar people, neutral territory, on leash
Unfamiliar people, neutral territory, off leash
Unfamiliar people, neutral territory, approaching/trying to pet
Children on bicycles, roller blades
Joggers (adult)
Cars/trucks going by, on leash
Babies
Children
Unfamiliar dogs, on leash
Unfamiliar dogs, off leash
Squirrels/cats/small animals approaching the dog
Person passing when dog in yard
Dog passing when the dog is in the yard
Veterinary visits
Owners leaving
Owners returning
Car rides
Stranger approaching car
Thunder
Loud noises
Roughhousing

How does dog react when a family member does the following?*

	Happy & Relaxed	Excited/hard to calm (jumps)	Neutral	Fear/Anxiety/Submits	Snarl and/or Growl	Bark	Snap/Bite	Don't Know/Don't Do
Walk by food while the dog eats regular dog food
Take a food dish while the dog eats
Walk by food while eating delicious food
Take away non-edible toy
Take away bone, rawhide
Take away a stolen non-food item (e.g., socks)
Take away stolen food items (including dirty tissues, paper towels)
Reach for dropped food atthe same time as the dog
Reach over head/pet on top of head
Pet on other parts of the dog's body
Brush
Bathe
Pick the dog up
Put on/take off the collar
Put on/take off the leash
Disturb while sleeping
Move while on furniture
Approach the dog when it's sitting with a favorite person
Hold back when excited (e.g., from running outdoors) NOT WHEN AGGRESSIVE
Hold back when aggressive (e.g., barking at another dog)
Verbal reprimand
Leash correction
Physical reprimand
Staring at dog

How does the dog react to a dog in the household?*

	Happy & Relaxed	Excited/hard to calm (jumps)	Neutral	Fear/Anxiety/Submits	Snarl and/or Growl	Bark	Snap/Bite	Don't Know/Don't Do
Around regular food
Around rawhides
Around treats
Around toys
Around favorite people
While on walks together
During play

Has your dog ever bitten a person?*

Yes

No

Unknown

If yes, describe the victim(s): age, gender, and actions (e.g., 10 year old boy waving a stick):

How bad was the worst bite your dog gave to a person (check all that apply):*

Made contact but didn't leave a mark

Small red mark

Bruised, didn't break skin

Broke skin, minor scrape

Broke skin, punctures

Multiple punctures

Punctures and tore flesh

Multiple bites at one time

Required emergency treatment

Have any bites been reported to Animal Control or other authorities?*

Yes

No

Comments:

Have any victims threatened/taken legal action because of an aggressive incident?*

Yes

No

If yes, describe incident:

What is the main behavior problem you wish to address at this appointment?*

Describe the very first incident of this problem. Try to remember the earliest occurrence of the problem, even if it wasn't as serious as it is now.

For instance, if your dog is aggressive to people, describe the first time she growled or barked at someone. Or if your dog has problems being left home alone, describe the first time he whined and cried when you left.

Include where the incident occurred, who else (human and animal) was present, what happened just before the incident, and how everyone reacted. Also include the date of the event and the dog's approximate age.*

Describe the most recent incident of this problem.

Include where the incident occurred, who else (human and animal) was present, what happened just before the incident, and how everyone reacted. Also include the date of the event and the dog's approximate age.*

Describe at least one other incident you feel illustrates the problem behavior. Try to remember the earliest occurrence of the problem, even if it wasn't as serious as it is now.

Include where the incident occurred, who else (human and animal) was present, what happened just before the incident, and how everyone reacted. Also include the date of the event and the dog's approximate age.*

If you noticed any changes in your dog's body language or facial expression before, during or after the incidents, please describe.*

What would you like to see as an outcome for your upcoming appointment?*

How frequently does this problem occur?*

>10 times/day

1-10 times/day

1-6 times/week

<1x/week

>1time/month

Is the frequency…*

Increasing

Decreasing

Unchanged

What percent of time that your dog is in a potentially problematic situation does the problem behavior occur?*

<25%

25-50%

51-75%

76-100%

Describe what you've tried to correct the problem and what the dog's response has been to each attempt.*

How serious do you and other members of the household find this problem:*

	Mild	Moderate	Severe	Intolerable
You
Person 1
Person 2
Person 3
Person 4

Please answer the following:*

	Yes	No
Has anyone suggested you rehome this dog?
Has anyone suggested you euthanize this dog?
Have you or a household member considered rehoming this dog?
Have you or a household member considered euthanizing this dog?

List other problem behaviors in order of importance to you. Due to the intense focus on your dog’s main problem, there may be limited opportunity to address these at the initial appointment

Canine Behavior Questionnaire

Patient

Pet Name:*

Breed*

Color*

Pet Birthdate:*

Weight (if known)*

Sex:*

If spayed or neutered, at what age was the procedure?

If not neutered, reasons for not neutering (check all that apply):

Rabies Vaccination Status:

Date of last Rabies vaccination (specify 1-year or 3-year vaccine)*

Household Information

People living in the household (include name, age, relationship)*

Other people in regular contact with the pet (e.g., pet sitters, housekeepers, relatives, friends, etc.). Please provide name, age, relationship.*

Type of house:*

Neighborhood:*

Do you have a yard?*

If yes, how big is the yard?

Is the yard fenced?*

If yes, how high is the fence and what material is it made of?

Other pets in the household (in order they came into the household). Please provide name, species, breed, gender, age now & age when obtained.*

Acquisition Information

How old was this dog when acquired?*

Where did you obtain this dog?*

Behavior of dog's parents/littermates (if known):

Describe previous home(s) (if known):

Why did you acquire this dog? (check all that apply):*

Medical History:

List any major illnesses/surgeries (dates):*

List ALL medications/treatments your dog is currently receiving, including heartworm, flea preventative, dietary supplements, and herbal/homeopathic treatments (provide name of medication, dosage/frequency given, and date started):*

Daily Activities and Routine:

When and where is the dog fed?*

Who feeds the dog?*

Types of food:*

Eating habits (check any that apply):

Where does your dog sleep at night?*

If disturbed while sleeping what is your dog's reaction (check all that apply)?*

Does your dog get regular leash walks?*

If no, why?*

If YES, who takes the dog for leash walks? How often and how long are the walks, and where do they occur?*

What do you use to walk the dog (check all that apply):*

How is your dog on leash:*

Does your dog get off-leash exercise?*

If yes, who takes the dog for off-leash exercise? Where, how often, for how long?

Where does your dog spend the most time when people are home:*

Where is your dog spend the most time when people are not home?

How long is your dog left alone on an average day? Between what times?*

What is your dog's reaction to being left alone (check all that apply):*

Describe a typical 24-hour day in your dog's life, starting with when and where the dog wakes up in the morning. Include feeding, exercise, and play times. If behavior problems occur at particular times of the day, include that information.*

Training:

Has your dog had any training?*

List type of classes, at what ages, and names of trainers:*

What training techniques or tools have you used (all that apply):*

Who in the household trained the dog?

What commands does your dog know?*

Did your dog enjoy training?*

How well does your dog obey commands without distractions:*

How well does your dog obey commands with distractions:*

Behavior Screens:

Does your dog engage in the following behaviors at least weekly?*

How does your dog react to the following?*

How does dog react when a family member does the following?*

How does the dog react to a dog in the household?*

Has your dog ever bitten a person?*

If yes, describe the victim(s): age, gender, and actions (e.g., 10 year old boy waving a stick):

How bad was the worst bite your dog gave to a person (check all that apply):*

Have any bites been reported to Animal Control or other authorities?*

Comments:

Have any victims threatened/taken legal action because of an aggressive incident?*

If yes, describe incident:

Primary Behavior Problem:

What is the main behavior problem you wish to address at this appointment?*

Describe the most recent incident of this problem. Include where the incident occurred, who else (human and animal) was present, what happened just before the incident, and how everyone reacted. Also include the date of the event and the dog's approximate age.*

If you noticed any changes in your dog's body language or facial expression before, during or after the incidents, please describe.*

What would you like to see as an outcome for your upcoming appointment?*

Frequency:

How frequently does this problem occur?*

Is the frequency…*

What percent of time that your dog is in a potentially problematic situation does the problem behavior occur?*

Describe the most recent incident of this problem.

Include where the incident occurred, who else (human and animal) was present, what happened just before the incident, and how everyone reacted. Also include the date of the event and the dog's approximate age.*