PHOENIX DOG TRAINING | DOG BEHAVIOR QUESTIONNAIRE

 

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Canine Behavior
Consultation Questionnaire

Please fill in the form below:

*required fields

GENERAL INFORMATION
*First Name: *Last Name:
Address: City:
State: Postal (zip) code:
Home Phone:
*e-mail:
Business Phone:
Fax:
Veterinarian/clinic:
Clinic Phone:
Referred by:

 

PET INFORMATION
Dog’s name: Breed: Color:
Date of birth: Weight: Sex:
Neutered?: Age neutered:
Any change after neutering?:
Age pet obtained:
Where did you obtain this pet?:
Pet store
stray
Breeder
shelter
Friend
Newspaper ad
Other:
Breeder, if applicable:
Behavior of parents or littermates:

 

REASON(S) FOR PRESENTATION

Please list behavior problems in
order of importance:

Problem: Rate: Length of time
problem
has
existed:
Frequency of problem
(e.g. once weekly,
daily)
1. severe
moderate
mild
2. severe
moderate
mild
3. severe
moderate
mild

 

INFORMATION ON PRESENTING
COMPLAINT(S)
What do you think has caused the problem(s):
Describe the problem/misbehavior – last incident:
(make sure to include such descriptions (if possible) of the dog’s body
posture, locations of other people or animals in the vicinity, circumstances
that you believe stimulated the problem, etc.)
Describe previous incidents:
Has there been a recent change in frequency of the
behavior?
What has been done so far to try and correct the
problem?
What has been the dogs response?
List any techniques that have been successful:
List any techniques that have made the problem
worse:
List any drugs that have been tried so far and the
dog’s response to the medication:
Drug Mg strength Frequency (e.g. once a day, twice a
week)
Length of time drug administered (e.g. days, 2
weeks, etc.)
Outcome (successful or not)

List any other dietary treatments, supplements or
remedies and the dogs response:

 

FAMILY / RELATIONSHIPS
List each family member: (including sex and
age)
Name: Sex: Age:
Male  
Female
Male  
Female
Male  
Female
Male  
Female
Male  
Female
Male  
Female
Male  
Female
How does your dog get along with each member of the
family?
Who feeds?
Who plays?
Who grooms?
Who gives treats?
Who trains?
Describe the family schedule, including how long the
dog is left alone:
List all the pets in your household:

Name

Species

Breed

Sex

Age
obtained

Age now

F
F
F
How do the pets get along with each other?

 

TRAINING
Any formal training?
YES
NO Class   Private Instructor
Trained at
home
How successful was training?
Is there any ongoing training?
YES
NOIf yes, describe:
Type of training collar used: (check
one)
Dog’s response:
Neck collar
Remote collar
(if yes,
indicate type e.g. shock, citronella, etc.)
Head halter (Gentle Leader®,
Halti®)
Body harness
Other (pinch,
prong)
How would you describe the training?

Reward-based  Assertive/domineering
Aversive/mostly corrections  Other

How well does your dog obey the following commands
(when asked for the FIRST time) for each household member? (list as a
percent)
Household member Sit Down Stay Come
Is there any other commands or tricks your dog
knows?

 

PUNISHMENT
Have you ever used any of
the following for
punishment?
YES/NO Reaction
1. Physical punishment? YES  NO
2. Noise punishment (shaker can, siren) YES  NO
3. Ultrasonic (Petagree®) YES  NO
4. Water Sprayer: YES  NO
5. Verbal reprimands: YES  NO
6. Physical handling: muzzle grasp YES  NO

pinning

YES  NO
7. Time out: YES  NO
8. Bobby traps/repellents: YES  NO

 

HANDLING
How does your dog react to the following types of
handling?
Nail trimming: Giving pills:
Brushing: Hugging/kissing:
Rubbing belly: Patting head:
Grabbing collar: Lifting:
Rolling over: Bathing:

 

MEDICAL SCREEN
Is there any past illness or present illness
currently under treatment?
Any apparent painful conditions?
YES
NO
Describe appetite:
Voracious  Normal  Finicky  Decreased
Any changes in stool?
YES
NO
Any changes in drinking?
More   Less   Same
Any change in urination?
Same  More frequently  Less frequently
Larger volumes
Smaller Volumes
Any food tolerances?
YES
NOIf so, what?
Is your pet on any other medications? (besides the
drugs listed under primary behavior complaint if any)

Drug Name: Dosage: Frequency Given
(times per
day)
Duration

 

REINFORCER ASSESSMENT
If your dog was allowed any treat, what would it
prefer? (List top five)
1. 2.
3. 4.
What other types of rewards does your dog enjoy?
(play toys, walks, attention / affection). List top five:
1. 2.
3. 4.

 

HOUSETRAINING SCREEN
(Skip this section-
if your pet is not housesoiling, )
Was your dog ever completely housetrained?
YES
NO
At what age was he/she considered housetrained?
How often does your pet housesoil? (i.e. several
x/day, weekly, or monthly, etc.)
Is it urine, stool or both?
When is the dog most likely to housesoil?
Do you have a doggie door?
YES
NO
Does your dog use the doggie door?
YES
NO
In what rooms does your dog tend to soil?
Is there a room/location in which the dog does NOT
soil?
Does your dog soil when when family members are
home?
Does your dog soil directly in front of a family
member?
What do you do when you find urine or stool in an
improper location?
Does your dog urine mark? (urinate on upright
objects)
How many times per day does your dog have a chance
to go outside to eliminate?
How long is the longest confinement without access
to outside? (if any)
Is your dog crated?
YES
NO    Is
there urine in the crate? YES   NO
Does your dog leak urine when:
Sleeping
Walking

Approached by owner
If approached by a stranger
Excited

Frightened

 

DEPARTURE BEHAVIOR SCREEN
How long is the dog left alone on an average day?
Is the dog left:
Outdoors
Access to both
Is your dog crated or confined on departure?
YES
NO
If crated, describe crate: Location of crate?
If confined other than a crate, please describe:
Has your dog been left at a kennel, veterinary
clinic or with family/friends?
If yes, describe your dogs reaction:
Does your dog exhibit any problem behaviors on your
departures? YES
NO
If no please skip this remaining section; If yes
continue with the following questions.
Describe your dog’s behavior when left alone:
Does the behavior differ depending on the length of
departure or the time of day left alone?
How does your dog act as you or other family members
are getting ready to leave? Describe:
Does the behavior differ depending on who is the
last to leave the home?
How does the dog react when the family returns?
Have you ever left the dog alone in the car? If so
how did it react?

 

AGGRESSION SCREEN
Has your pet displayed any of the following?

Threatening display?
YES
NO
Growling?
YES
NO
Bite attempts?
YES
NO
Bites?
YES
NO

Skip the next section if your pet has displayed any
of the above, but they have been resolved, or controlled to your
satisfaction.
Situation Growled Attempted to bite Bitten No reaction Briefly explain
Petting/handling:
Eating/approaching while eating:
Chewing stolen toys/objects attempting to take
away from dog:
Trimming nails/bathing/brushing:
Staring at dog:
Scolding dog:
Leash or collar correction:
Physically reprimanding dog:
Raising hand over dog:
Bend or lean over dog:
Hug or kiss dog:
Grabbing collar:
Rolling over:
Disturbing while sleeping:
While dog is on furniture/bed, attempting to
remove dog:
Skip this section and move to the next if your pet
is not aggressive towards people.

Aggression Towards People

In your opinion, what is the potential for injury to
another person?
Has your dog ever bitten hard enough to break skin
or cause injury? YES
NO
If yes,
describe:
Number of bites that have broken skin:
Body parts typically bitten:
If your dog has bitten a person, how old was the dog
the first time he/she bit? (months or years)
Is your dog ever aggressive to members of the
immediate family? YES
NO
If yes,
who? Describe:
Is your dog ever aggressive to visitors in your
home? YES
NO
If yes, who?
Describe:
Is your dog aggressive to people off your property?
YES
NO
If yes, where
the people known, strangers or both? Explain:
Is there a particular person or type (age, sex,
uniforms) that your dog is most likely to threaten or bite?
Is there a particular location or situation where
aggression is most likely to occur?
When your dog threatens, attempts to bite or bites,
how do you handle the situation and what is the dog’s reaction?
How would you describe your dog’s expression and
postures at the time of aggression? (hackles raise, ear forward, tail back,
tail up or tucked between legs and under, cowering, running forward and then
retreating):
Skip this section and move to the next if your dog
is not aggressive towards other dogs.

Aggression Towards Other
Dogs

In your opinion, what is the potential for injury to
another dog?
How old was your dog when you first noticed
aggression to other dog(s)?
(months or years)
Has your dog ever bitten hard enough to break skin
or cause injury requiring medical attention?
YES
NO
Number of bites that have broken skin
Body parts typically bitten:
Is there a particular location or situation where
aggression is most likely to occur?

Additional Aggression
Problems:

(If yes to a problem briefly describe.)

Destructive chewing YES   NO
Barking YES   NO
Whining YES   NO
Housesoiling urine YES   NO
Housesoiling stool YES   NO
Stool eating YES   NO
Hunting / predation YES   NO
Jumps up (owners) YES   NO
Jumps up (guests) YES   NO
Garbage raiding YES   NO
Food stealing YES   NO
Pushy – wants own way YES   NO
Only listens when feels like it YES   NO
Sexual habits:
Masturbation, Roaming,
Mounting, Urine marking
YES   NO
Chews/licks self: (If a problem, note location
on body and frequency)
YES   NO
Tail biting YES   NO
Fly chasing YES   NO
Staring at / chasing imaginary
objects
YES   NO
Uncontrollable urination when excited YES   NO
Uncontrollable urination when
frightened
YES   NO
Bedwetting (while sleeping) YES   NO
Eats non-food items (Pica) YES   NO
Licks objects YES   NO
Excitability YES   NO
Overactivity YES   NO
Phobias (thunder / cars, etc.) YES   NO
Shyness / timidity (nonaggressive) YES   NO
Additional problems not listed:

 

SUBMIT QUESTIONNAIRE

 

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