Canine Behavior History Form

Please complete this form and we will call you to schedule an appointment. Please videotape your pet performing the behavior(s) before your visit, if possible. For safety reasons, any dog with a known history of aggressive behavior must wear a basket muzzle upon entrance to the hospital. Thank you and we look forward to working with you and your pet(s)!
Client Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone (Home)
Work
Alternate
Email*
Other Contact Information
Dog Information
Name*
Breed*
Age*
Sex*
Weight*
Neutered/Spayed*
- Yes
- No
At what age?
Referring Veterinarian Information
Doctor Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Email

Save and Continue Later

Step 1 of 7

Client Information

Dog Information

Referring Veterinarian Information

Chief Complaint

Dog's Environment

Early History

Education

Feeding

Sexual and Maternal

Grooming

Social

Learning

Sleep

Medical

Aggression

For the following questions and situations

Please use the following characteristics when describing the reaction:

Situation

Owner reaches over dog

Owner reaches for dog's face

Owner stares at dog

Owner reprimands dog physically

Owner reprimands dog verbally

Owner attempts to approach/take away dog's food

Owner attempts to approach/take away dog's toy

Owner walks past dog

Owner runs past dog

Dog does not allow owners to move freely through the house

Dog aggressive only when particular family member present but not aggressive toward that family member

Stranger reaches over dog

Stranger stares at dog

Stranger comes to door

Stranger enters yard while owner present

Stranger enters yard while owner not present

Preferred owner holds dog on leash while stranger approaches dog off property

Non-preferred owner holds dog on leash while stranger approaches dog off property

Stranger approaches off leash

Another dog mounts hind end of your dog

Another dog stares at your dog

Another dog attempts to approach/take away dog's food

Another dog attempts to approach/take away toy

Dog does not allow other dogs to move freely through the house

Dog aggressive to other dogs only when family members present

Another dog attempts to play with your dog

Another dog approaches when your dog is on leash

Another dog approaches when your dog is off leash

Dog aggressive after acting submissive to another dog

Dog sees cat indoors

Dog sees cat outdoors

Dog sees squirrel

Dog sees other small animal

Severity of Problem