Dog Behavior Intake Form

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Owner Name(Required)

First Last

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Address(Required)

Street Address City State ZIP Code

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Phone(Required)

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Email(Required)

Pet's Name(Required)

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Breed(Required)

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Sex(Required)

Age(Required)

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Color(Required)

Who referred you to the behavioral medicine department?(Required)

Please list all veterinary hospitals where your dog has been seen in the past 5 years.

IMAGE AND VIDEO CONSENT —

We may take pictures and videos as a part of your pet’s appointment. Below is a consent questionnaire for our use of images of your pet. When used, there will be no identifying information of your pet or you, such as your name. Please consent below to whichever options works best for you.

Image and Video Consent Choice(Required)

My pet’s pictures and videos can be used for my pet’s medical record, textbooks, and veterinary publications, including journals, electronic publications, and veterinary presentations.

My pet’s pictures and videos are to be used for my pet’s medical record only.

Do not use my pet’s picture for any purpose, including in his or her medical record.

DOG BEHAVIORAL QUESTIONNAIRE —

PLEASE MARK ALL OF THE APPROPRIATE BOXES AND FILL IN THE BLANKS TO THE BEST OF YOUR ABILITY

How long have you had your dog?(Required)

Where did you get your dog?(Required)

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Has your dog had any other owners?(Required)

Yes

How many previous owners has your dog had?(Required)

If you know, please explain why your dog was relinquished by the previous owner(s):(Required)

How many people are in your household?(Required)

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Has there been any significant change in your household's routine or schedule in the past 3 months?(Required)

What are your goals for this appointment?(Required)

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Are there any children in the house or who come to visit regularly?(Required)

Yes

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If you feel that the relationship of the dog with a particular person is important to the assessment and treatment of the problem for which you are bringing your dog, please describe.

Tell us about your pet's environment. Check all that apply.(Required)

Leash walked

Play in fenced yard

Dog park

Electric fence

Solid wood fence

Chain link, iron, or aluminum fence

Tie out

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How many play sessions does you dog get per day?(Required)

Do you have multiple pets?(Required)

Yes

Does your pet sleep with the other pets?(Required)

Yes

Does your pet lick or groom the other pets?(Required)

Yes

Does your pet play with your other pets?(Required)

Yes

List the other animals in the household and describe their relationship with the patient.(Required)

MEDICAL HISTORY

Please describe any significant medical illnesses, treatments, and the outcomes.(Required)

What do you feed your pet?(Required)

Does your pet have any allergies or food sensitives? If yes, please describe.(Required)

Please check all the previous treatments tried.

Does your dog lick excessively (you, the floor, himself, other objects, other people)?(Required)

Yes

Have you ever worked with a dog training professional with this pet before?(Required)

Yes

Have you worked with a dog training professional in the past three months?(Required)

Yes

Please list the company, trainer name, and what behaviors were taught. Include puppy classes. This helps us to know what behaviors and methods have been used thus far in training your dog.(Required)

Are you planning to continue to work with the dog training professionals listed above?(Required)

Yes

SLEEPING BEHAVIORS

Does your pet sleep through the night?(Required)

Yes

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Have you noticed any change in your pet's sleeping patterns in the past three months?(Required)

Yes

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Does your pet take naps during the day when you are home?(Required)

Yes

AGGRESSIVE BEHAVIORS

Has your dog shown aggression (biting, lunging, barking, growling)?(Required)

Yes

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Are there people in your household or who regularly come to visit who are at greater risk if bitten?(Required)

Yes

Who are the people who are at greater risk if bitten?(Required)

Elderly

Children

Adults or children who have illnesses which would reduce healing or increase risk

Has your dog ever bitten a person?(Required)

Yes

Number of bites?(Required)

Number of bites that broke the skin?(Required)

Number of bites that were reported to pubic heath authorities?(Required)

Has your dog ever bitten a dog?(Required)

Yes

Number of bites?(Required)

Who is your dog aggressive toward? Check all that apply.(Required)

Describe "other"(Required)

When is your dog aggressive? Check all that apply(Required)

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What does your dog look like when aggressive? Check all that apply.(Required)

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What does your dog look like when visitors enter the home? Check all that apply.(Required)

Jumps

Barks

Growls

Bites

Runs away

Tries to escape

Lunges

Hides

Other

Describe "other"(Required)

Please check all previous treatments tried:(Required)

Please add any additional information that you would like to share about how, when, or to whom your pet is aggressive.

NOISE BEHAVIORS

Does your dog exhibit a behavior change with any of the following?(Required)

Describe "other"(Required)

What does your dog do when they hear a scary sound? Check all that apply.(Required)

Describe "other"(Required)

How long does it take after a sound for your dog to calm down entirely?(Required)

Please add any additional information that you would like to share about your dog's reaction to scary sounds.

SEPARATION BEHAVIORS

What does your dog look like when you're preparing to leave the house? Check all that apply.(Required)

Follows you to the door

Hides

Trembles

Tries to block you from leaving

Barks

Tries to escape

No separation behaviors

When your dog is alone, does he or she do any of the following? Check all that apply.(Required)

Bark

Destroy things

Howl

Tremble

Pant

Wait at the door

Sleeps or relaxes

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When you return, how long does your dog take to calm down?

1 minute

5 minutes

10 minutes

Over 10 minutes

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Where is your dog when you are not home?(Required)

Describe "other"(Required)

Does your dog exhibit the behavior every time that you depart?

Yes

Does your dog exhibit the behavior only when alone?

Yes

Please add any additional information that you would like to share about your dog's anxiety or panic when you leave.

CAR RIDES

What does your dog look like in the car? Check all that apply.(Required)

Looks calm

Pants

Paces

Hides

Trembles

Tries to get to you

Barks

Please add any additional information you'd like to share about your dogs behavior in the car.

REPETITIVE BEHAVIORS

Does your dog exhibit any of the following behaviors? Check all that apply.

Stares at and/or chases lights and shadows

Runs in circles

Chases tail

Fly snapping

EUTHANASIA / REHOMING

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Did someone recommend euthanasia before your visit to us?(Required)

Yes

Have you considered euthanasia before this visit?(Required)

Yes

Have you considered re-homing your dog before your visit?(Required)

Yes

Anything else you'd like to share with us about your dog?

AUTHORIZATION

I am the owner of the animal seeking behavioral medicine treatment from Gold Coast Center for Veterinary Care, and 18 years of age or older. Behavioral treatment, training, and advice, when properly maintained after completion, can be very helpful in resolving problem behaviors in animals. Because each pet is an individual, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior, including aggression, is unpredictable and will remain unpredictable after its treatment. Gold Coast Center for Veterinary Care cannot promise that the animal’s behavior service treatment, training or advice will completely eliminate the animals potential danger to persons or completely control the animal’s aggressiveness.

I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.

I understand that all fees are to be paid at the time of service and accept full responsibility for the charges incurred in the treatment of my pet.

Telehealth appointments may be recorded for internal training only.

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