PetShrink
Phone (978) 838-0143/(508) 494 5405: Fax (978) 838-0216
dvm@petshrink.com
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:
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
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Yes |
No |
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Acquired after 3 months? |
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Acquired at 5 weeks of
age or less? |
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Acquired from shelter or
pound? |
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Multiple owners? |
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Pet shop? |
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Orphan/hand raised? |
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Single puppy in litter? |
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BEHAVIOR
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No |
Mild |
Moderate |
Severe |
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Follows owner around
house |
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Predeparture anxiety |
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1. sound of car keys |
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2. put on coat/shoes |
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3. aggression when owner
leaves |
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4. other/specify |
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Post departure behavior |
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1. Excessive
whining/barking (within 30 minutes of departure) |
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2. Decreased activity |
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3. Depressed |
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4. Loss of appetite |
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Only in owner's
absence |
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1. Destroys property |
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2. Urinates/defecates in
home |
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Outcome |
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Diarrhea, vomiting,
excessive licking etc (specify) |
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Excessive
greeting/demanding on owner’s return (jumping, hyperactivity, barking >
3minutes) |
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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 |
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Walk past dog
while eating |
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Add food
while dog is eating |
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Take away
real bone or rawhide |
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Walk by dog
with bone/rawhide |
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Touch
delicious food dog is eating |
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Take away
stolen object |
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Physically
wake dog up |
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Physically
disturb resting dog |
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Restrain dog
by collar or scruff |
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Lift dog |
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Pet dog |
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Medicate dog |
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Handle dog’s
face and mouth |
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Handle dog’s
feet |
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Trim dog’s
nails |
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Groom dog |
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Bathe or
towel dog |
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Take off/put
on collar |
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Reach for or
grab collar |
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Hold muzzle |
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Stare at the
dog |
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Reprimand dog
in angry voice |
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Visually
threaten (hand/newspaper) |
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Hit dog |
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Walk by dog
in crate |
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Walk by dog
on furniture |
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Remove dog from
furniture: physically or verbally |
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Make dog
respond to a command |
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Force dog
into a down |
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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?