Behavioral Data Sheet - Canine

Instructions: Please fill out the forms giving as much relevant information as possible. While not all of this will appear to relate to your dog, completing the forms may disclose underlying problems that might otherwise be missed.

DATE:

NAME & ADDRESS OF OWNER:

TELEPHONE: FAX: E-MAIL:

NAME OF DOG: BREED:

AGE OF DOG NOW: AGE AT WHICH DOG WAS OBTAINED:

WEIGHT: COLOR:

SEX: SPAYED/NEUTERED:

AGE OF NEUTERING:

REASON(S) FOR NEUTERING:

ANY BEHAVIORAL CHANGES AFTER NEUTERING:

MEDICAL PROBLEMS:

ANY CURRENT MEDICATIONS (INC HEARTWORM): PLEASE GIVE DOSES IF KNOWN:

DOES YOUR DOG SHOW ANY OF THE FOLLOWING (these are potential clinical signs of hypothyroidism, and should be noted even if mild)?

____Excessive shedding, patchy hair loss or “rat tail”
____Dry skin or dull, dry hair coat
____Recurrent infections (especially ear, skin and foot infections)
____Tendency to gain weight
____Heat seeking behavior (acts cold)
____Increased sleep time
____Hyperactivity
____Slow learning
____Seizures
____Worried look, tragic facial expression or looking “old”
____Reduced hearing, sight and scenting ability
____Chronic gastrointestinal symptoms
____Loss of muscle or bladder tone
____Head tilt
____Change in character of bark
____Exercise intolerance
____Infertility, false pregnancy or weak, dying or stillborn puppies
____Recurring eye infections
____Premature graying

BEHAVIORAL PROBLEMS: If the dog has more than one problem please include information on each problem separately. Please answer as fully as possible.

Problem:

Age of Onset:

Duration of each incident:

Frequency of occurrence:

Have there been any changes in the pattern, frequency, intensity and/or length of incidents from the time of onset to the present?:

Can the dog be interrupted when engaged in the behavior?:

What is the time interval between the behavior stopping and resuming?

Describe any methods used to treat the behavior and the dog’s response to those methods:

DOG’S HISTORY:

Where did you get the dog?

Do you know if the dog’s parents or siblings engaged in similar or other abnormal behaviors?

List people living in the house with the dog; please include the ages of any children in the household:

List other animals in the household, their species, breed, age, sex (neutered?). Please indicate which of these animals were in the household prior to acquisition of this dog. For those obtained afterwards, please note any relationship to this dog’s behavior problem(s):

Describe interactions between the dog and family members:

Describe interactions between the dog and other animals in the household:

Describe interaction of dog with strangers, both those coming into the house/owner’s property and those encountered off the dog’s property:

Describe the dog’s interactions with dogs and other animals outside the home:

Describe the dogs behavior in the veterinary office and during examination:

Does the dog live primarily inside or outside, describe any restrictions to dog’s movements inside the house/kennel etc:

DAILY ROUTINE:

Please describe a typical 24-hour period in the dog’s life. Begin with where and when the dog wakes up in the morning:

DIET:

Type of food:

Frequency of feeding and amount fed

Other food, supplements, table scraps:

EXERCISE:

Time spent and location on leash:

Time spent and location off leash:

Time spent playing actively with owner. Describe activities that take place:

Time spent actively playing with other animals:

OBEDIENCE TRAINING:

Have you attended obedience classes with your dog?:

Does your dog do the following consistently (circle where appropriate):

sit stay down heel come stand for grooming fetch do tricks

Situations in which your dog is less likely to obey you:

Does your dog work well for (circle where appropriate)?:

food ball/Frisbee/retrieve game praise petting no reward

INTERACTIVE BEHAVIOR:

Does your dog demand to be petted?

Does your dog ever seem irritated by or to resent petting?:

Does your dog bark excessively?:

Does your dog cower or run away if people talk loudly or act boisterously?:

Does your dog ever urinate or roll over on his/her back when greeting you?:

Does your dog ever urinate or roll over on his/her back when greeting strangers?:

Does your dog ever urinate or roll over on his/her back when greeting strange dogs?:

Is your dog comfortable in crowds?:

How does your dog act when strangers come to the house?:

How does your dog act when he meets/passes strangers away from home?:

How does your dog act when he meets strange dogs?:

Both on leash:

Both off leash:

When he is leashed and other dog is free?:

Is your dog frightened excessively by (circle where appropriate):

thunderstorms flies gunshots fireworks other(specify)

Does your dog chase (circle where appropriate):

running child(ren) jogger bicyclist cats or other furry animals cars

Does your dog urinate or defecate in the house?:

HISTORY

	Yes	No
Acquired after 3 months?
Acquired at 5 weeks of age or less?
Acquired from shelter or pound?
Multiple owners?
Pet shop?
Orphan/hand raised?
Single puppy in litter?

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BEHAVIOR

	No	Mild	Moderate	Severe
Follows owner around house
Predeparture anxiety
1. sound of car keys
2. put on coat/shoes
3. aggression when owner leaves
4. other/specify
Post departure behavior
1. Excessive whining/barking (within 30 minutes of departure)
2. Decreased activity
3. Depressed
4. Loss of appetite
Only in owner's absence
1. Destroys property
2. Urinates/defecates in home
Outcome
Diarrhea, vomiting, excessive licking etc (specify)
Excessive greeting/demanding on owner’s return (jumping, hyperactivity, barking > 3minutes)

Please check the appropriate box if your dog shows any of the listed behaviors when you or any family member do the following:

Action	Growl	Lift lip	Snap	Bite	No aggression	Not tried
Touch dog’s food while eating
Walk past dog while eating
Add food while dog is eating
Take away real bone or rawhide
Walk by dog with bone/rawhide
Touch delicious food dog is eating
Take away stolen object
Physically wake dog up
Physically disturb resting dog
Restrain dog by collar or scruff
Lift dog
Pet dog
Medicate dog
Handle dog’s face and mouth
Handle dog’s feet
Trim dog’s nails
Groom dog
Bathe or towel dog
Take off/put on collar
Reach for or grab collar
Hold muzzle
Stare at the dog
Reprimand dog in angry voice
Visually threaten (hand/newspaper)
Hit dog
Walk by dog in crate
Walk by dog on furniture
Remove dog from furniture: physically or verbally
Make dog respond to a command
Force dog into a down

Does your dog get a glazed look in his/her eye?

Does your dog have a Jeckyl and Hyde personality?

Do you consider your dog hyperactive?