Behavior Monitoring Questionnaire

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1 Behavior Monitoring Questionnaire Please complete the following information and submit 24hrs before scheduled appointment. Behavior problems can be frustrating and difficult to correct. The information provided in the following questionnaire will be very important for accurate diagnosis and treatment of your pet's problem(s). Please be complete and provide as much detail as possible. When describing events and problems, details your pet's specific behavior pattern and not your interpretation of what your pet is doing. Owner: Date: Address: Phone: (H) (W): Pet's Name: Species: Age: Breed: Sex: Altered? If yes, at what age?: Where did you obtain this pet? (e.g. breeder, friend, pet store, etc.): At what age did you obtain this pet?: Why did you pick this particular pet and for what purpose? (e.g. show, companionship, breeding, etc.) Is this your first experience with a pet of species or breed?: List all medications your pet is currently receiving (including flea and heartworm prevention) of has received in the last 3 months and how long the pet has been taking them.

2 List all medical and surgical conditions affecting your pet and when they were done. What is your pet's regular- diet, include brand and amount fed. Also indicate if your pet receives tablet scraps or supplements. How often is your pet fed? By whom? Where? What treats does your pet receive and why? What percentage of time does your pet spend indoors? Outdoors? Where does your pet stay: During the day: During the night: When left alone: When guest are present: How long is the pet left alone during the day? Night? Is your pet allowed on the furniture? What toys does your pet have to play with and which does it use? What type and how much exercise does your pet receive and when?

3 Does your pet roam free in the neighborhood? Cumming Veterinary Clinic Have you trained a dog/cat before? Explain: Has your pet received any formal training? If so, please describe what type, where it occurred and what the outcome was. What will your pet do on command? For the commands listed above, what percentage of time will the pet respond on the first command while off leash with no physical prompting? List any other animals in the household. Include sex, age, and if altered or intact

4 Please describe the type and amount of exposure your pet received during the first 4 months of its life to: People: Other animals, especially those of its own species: Does your pet get along with other animals? List all persons in the household and their daily schedule. How does your pet react to strangers inside your house? Outside? Describe your pet's personality. How does your pet act just before you leave the house? When you return?

5 Describe your pet's behavior problem(s). Use additional sheet if necessary. When did these first begin (month and year)? Describe when the problem(s) are most likely to occur and how frequently they occur Has any change occurred in the frequency, intensity, or appearance of the problem(s)? Explain:

6 Were there any changes in your pet's environment within the 6 months prior to the onset of the problem(s)? new animal moved or redecorated new baby or person in house schedule change guest (animal or human) change in diet change in pets living arrangements other How did the pet react of these changes? What corrections or methods have been used to try to correct the problem? How did the pet react to these methods? If the pet was punished for these behaviors, how did the pet react during and immediately after the punishment? Please list any other behavior problems displayed by your pet: A. Digging F. Sexual K. Eat nonfood items B. Vocalization G. House-soiling L. Jumps up C. Chewing H. Learning M. Bites/growls D. Unruly I. Grooming (excessive) N. Fights E. Feeding J. Shy/timid O. Other:

7 Please indicate any other additional information you feel might be helpful. Use the back or an additional sheet if necessary. Please describe the last 2 incidents of aggressive behavior in your pet. Provide as much detail as possible.

8 Aggression Screen L = Lunges B = Bites G = Growls/snarls S = Snaps Br = Barks For each of the following items, please indicate which if any of the above behaviors your dog exhibits in each circumstance. Please list all that are applicable; if your dog lunges and growls, indicate L and G 1. Petting on head or shoulders 2. Handing feet 3. Grooming by owner 4. Grooming by groomer or stranger 5. Handling at or by veterinarian 6. Restraining pet for medicating 7. Disturb pet while sleeping 8. Reprimand verbally 9. Reprimand physically 10. Correct or jerk with leash 11. Owner near food bowl 12. Owner take food bowl 13. Human approaches pet with treat or bone 14. Stranger approaches pet with treat or bone 15. Taking food/treats from pet 16. Taking stolen items from pet 17. Owner staring into eyes 18. Stranger staring into eyes 19. Stranger approaches when dog alone 20. Stranger approaches when dog with owner 21. Approached by child 22. Approached by dog while pet on leash 23. Approached by dog while off leash 24. Human approaches pet in car 25. Clipping toe nails ALWAYS SOMETIMES NEVER

9 Interdog Aggression Study Please describe your dog's posture and actions when interacting with another dog. How long has your dog been exhibiting this behavior? Has the behavior changed over time? Explain: Does this behavior change when the dog is off leash? If so, how? Is the aggression directed toward any particular breed, sex, size, age or color dog? If so, explain: What percentage of dogs encountered trigger aggressive reactions?

10 Has your dog been in actual physical contact with dogs triggering aggressive displays? Were the dogs on leash, muzzled, or unrestrained? If so, what occurred during this incident? Has your dog ever injured or killed another dog? Please elaborate: Please describe the extent and type of exposure your dog received to other dogs during the first year of its life. This questionnaire was developed by Lore I Haug, DVM. Texas A&M University/Veterinary Medical Teaching Hospital

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