PART II. PRINCIPAL BEHAVIORAL COMPLAINT

PART III. HOME ENVIRONMENT

C A N I N E B E H A V I O R A L H I S T O R Y F O R M

Dolittle’s Canine Behavior Counseling

11333 Moorpark St. #85

Toluca Lake, CA 91602-2618

818-802-5481

818-990-0330 Fax

dolittlesdogs@yahoo.com

The information you provide here is very important in the diagnosis and treatment of your dog’s behavior problem. Please fill out this form as completely and accurately as possible. Circle or check the applicable choices where given. Use N/A to indicate “not applicable” to your dog or situation. If additional space is needed, attach a separate sheet. E-Mail or fax this form Dolittle’s Canine Behavior Counseling prior to setting up your appointment. Thank you.

Today’s Date:_________________________________________

PART I. DATA

Last Name____________________________First Name_____________________Spouse______________________

Street Address___________________________________________________________________________________

City_____________________________State_______________________Zip_________________________________

Home Phone______________________Work Phone______________________Fax___________________________

E-mail address___________________________________________________________________________________

How did you learn of Dolittle’s Canine Behavior Counseling?______________________________________________

Pet’s Name______________________________________Breed__________________________________________

Birthdate_________________Age______________ Age Obtained_______________ Weight ____________________

Sex (circle one): Male (intact) Male (neutered) Female (intact) Female (spayed)

Age neutered or spayed____________________________________________________________________________

Where did you obtain this pet: BREEDER, FRIEND, PET STORE, ANIMAL SHELTER, RESCUE. OTHER

Behavior problems of parents or littermates, if known____________________________________________________

Use of pet COMPANION WORKING DOG SHOW DOG PROTECTION OTHER________________________

Your primary veterinarian’s name_________________________________________________________________

Note: After any behavioral consultation, we will send a letter of summary to your veterinarian.

Name of Clinic or Hospital__________________________________________________________________________

Street Address___________________________________________________________________________________

City ___________________________________________State_______________________Zip___________________

Office Phone___________________________________Fax_______________________________________________

Summarize the primary behavior problem in one sentence________________________________________________

_______________________________________________________________________________________________

How would you describe the severity of this problem? MILD MODERATE SEVERE

Have you considered euthanasia? YES NO Please comment_______________________________________

If you cannot solve the problem have you thought about giving up your dog? YES NO

Describe the last two incidents in as much detail as possible. Include an approximate date of each incident. Use additional sheets if necessary.

1. _____________________________________________________________________________________________

_______________________________________________________________________________________________

2. _____________________________________________________________________________________________

_______________________________________________________________________________________________

FREQUENCY

Please indicate the number of times the problem has occurred in each of the times indicated

	Past Week	Past Month	Past Year	Total Number of Times
No. of Times

BACKGROUND INFORMATION

Question

Your Response

At what age was your pet when the problem began?

Were there changes in the home at that time?

List techniques you have used to correct the problem.

Put (+) next to techniques that seem to have helped.

Put (-) next to techniques that made things worse.

Put (0) next to techniques that had no effect.

Have any drugs or remedies been tried for this problem? Please list.

Put (+) next to techniques that seem to have helped.

Put (-) next to techniques that made things worse.

Put (0) next to techniques that had no effect.

What do you think is the reason for your dog’s problem?

NO REACTION

AVOIDS

RESISTS

GROWLS

COMMENTS

Trimming nails

Giving pill

Cleaning ears

PERSONS LIVING IN THE HOUSEHOLD

List each person living in the household, including sex, age, time away from home (for example 9am-5pm), and comment on that person’s relationship with your pet (for example: “feeds dog”, or “is afraid of dog”).

Name	Age	Sex	Hours Away	Relationship with Pet
		M F
		M F
		M F
		M F
		M F

PETS LIVING IN THE HOUSEHOLD

List all other pets in household. Comment on the relationships between the dog with the behavior problem and your other pets (for example: “get along” or “dominates dog.”)

Name	Species	Breed	Age	Sex	Comments

DIET

Food/Treat	Brand name	How often given?	Desire for this food type
Dog food (canned)			mild moderate strong
Dog food (dry)			mild moderate strong
Dog food (additional)			mild moderate strong
Table scraps/people food			mild moderate strong
Treats			mild moderate strong
Supplement/Vitamin			mild moderate strong

LOCATION/ACTIVITY/EXERCISE

Situation	Amount of time per day or per week dog spends at this site/acitvity	Indicate location (loose in house, in kitchen, in crate or pen, at park, etc)	Indicate what dog wears (nothing, collar, harness, choke chain, prong collar, halter,etc)
In house, per day
In yard, per day
On walk, per day
Playtime, per day
Asleep, per night
Jogging or structured exercise, per week
Off leash (free), per week
Obedience training, per week

Do you have a fenced yard? Yes No If yes, what type of fence____________________________________________

What is your pet’s favorite toy or game?_______________________________________________________________

PART IV. BEHAVIORAL PROFILE

TRAINING

Describe any obedience training_____________________________________________________________________

Age at which obedience training started_______________________________________________________________

Success at obedience training: POOR FAIR MODERATE EXCELLENT

What commands work best now?____________________________________________________________________

Who in the family has the best control?_______________________________________________________________

HANDLING

Check how your dog responds to the following tasks