1. Name of client(s): 2a. Today s date: (day) / (mo) / (year) 2b. Dog s date of birth: (day) / (mo) / (year) 3. Patient: 4a.
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1 1 Survey Questionnaire About General Canine Behaviors* When used at each visit, this questionnaire will help clients and veterinarians assess the potential for behavioral problems in your dog so that help can be provided early. 1. Name of client(s): 2a. Today s date: (day) / (mo) / (year) 2b. Dog s date of birth: (day) / (mo) / (year) 3. Patient: 4a. Breed: 4b. Do you know your dog s weight? Yes lb 4c. Sex: Male Male castrated/neutered Female Female spayed/neutered 4d. If your dog is castrated or spayed [neutered] at what age was this done? weeks/months (circle) 5a. Age at which your dog was adopted? 5b. How many homes has your dog had? 5c. How long have you had this dog? a. weeks / months (circle) b unknown c. months d. total # of dogs in home e. total # of cats in home f. total # of people in home 6. Age in weeks at which your dog was definitively housetrained (e.g., no accidents in the house) weeks 7. Does your dog urinate anywhere in the house that you dislike now? Yes If you answered Yes, a. Where is the dog urinating that you find undesirable (list all areas)? b. How many times per week is the dog urinating in places you find undesirable? c. At what time of day is the urination occurring? d. Is the pattern different on days when you are home and days you are not home? e. Are you at work during the hours when the dog? f. How many times per day does your dog usually urinate?
2 2 8. Does your dog defecate in the house anywhere that you dislike now? If you answered Yes, a. Where is the dog defecating? b. How many times per week is the dog defecating in places you find undesirable? c. At what time of day is the defecation occurring? d. Is the pattern different on days when you are home and days you are not home? e. Are you at work during the hours when the dog? f. How many times per day does your dog usually defecate? 9. Does your dog have periodic or sporadic bouts of diarrhea or loose stool? 10. Did your dog destroy any objects while teething as a puppy? If you answered Yes, what objects did the dog destroy? Does your dog destroy anything now (sofas, clothing, rugs, doors, windows, et cetera) now? If you answered Yes, what does the dog destroy, and when does he or she do it (are you home, or are you gone)? Object When home When gone 12. Does your dog mouth anything or anyone? If you answered Yes, what or whom does the dog mouth? 13. Does your dog play with toys? If you answered Yes, with whom does your dog play with toys? himself/herself cats other dogs humans
3 3 14. Does your dog exhibit any vocalization about which you are concerned? If you answered Yes, what is/are the vocalization(s) and when do they occur? Vocalization barking howling Situation in which it occurs growling whining snarling 15. Does your dog react to storms? If you answered Yes, what happens? 16. Does your dog react to fireworks? If you answered Yes, what happens?
4 4 17. Does your dog react to other noises? If you answered Yes, what kinds of noises cause the dog to react? What does the dog do? 18. Have you ever been concerned that your dog is aggressive to people? 19. Have you ever been concerned that your dog is aggressive to dogs? 20. Have you ever been concerned that your dog is aggressive to animals other than dogs? 21. Has your dog even bitten anyone, regardless of the circumstances? If you answered Yes, please describe the circumstances: 22. Is your dog distressed when left alone? If you answered Yes, what does the dog do? barks/howls doesn t eat other, specify please
5 5 23. Has your dog had any changes in sleep habits (awakens at night, sleeps all the time, never sleeps, cries in sleep, etc.)? 24. Has your dog had any changes in eating habits (changes in frequency, preference, amount consumed, ease of handling food, etc.)? 25. Has your dog had any changes in locomotor behaviors or his or her ability to get around or jump on the bed, and the like (doesn t get on furniture anymore, avoids tile floors, avoids rungs, etc.)? 26. Has anyone ever told you that they were afraid of your dog? If you answered Yes, what did the person say? 27. Has anyone every told you that your dog was ill-mannered? If you answered Yes, why or what did the dog do that made the person say this? 28. What kind of lead/leash do you use for your dog? leather fabric chain other rope don t use a lead/leash 29. What type of collar or harness do you use for your dog flat buckle collar leather or fabric choke chain Martingale chain Halti other head collar Easy Walk harness fabric choke Martingale fabric Gentle Leader Sensation harness Sporn/Lupi /-pull harness DreamWalker harness other harness don t use a harness other collar don t use a collar 30. Is the dog exhibiting any behaviors about which you are concerned, worried or would like more information? Yes If you answered Yes, please list these behaviors below: * From Overall KL. Manual of Clinical Behavioral Medicine for Dogs and Cats. St. Louis, Mo.: Elsevier; 2008; in press. Reproduced with permission.
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