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Canine History Form

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Client Information

Dog Information

Veterinarian Information

Who is your regular veterinarian?

Behavioral Information

Chronology of the Behavior Problem

Describe several examples in detail:

Home Environment

Please list the people (including you) living in your household and ages of children.

Please list all animals in the household including the patient, in the sequence in which they were obtained.

Dog's Background

Where did you get this dog?

Diet and Feeding

Daily Schedule - Typical 24 hour day

Obedience Training

What percentage of the time does your dog obey the following commands for each member of the family?

What is your dog's activity level in general? Required

Medical History

Aggression Screen

Please indicate your dog’s reaction to each of the listed scenarios below using one of the following options.

GR = Growl

SL = Snarl/bare teeth

SB = Snap/Bite

NR = No Reaction

NA = Not Applicable

Pet dog Required
Hug dog Required
Kiss dog Required
Lift dog Required
Call off furniture Required
Push or pull off furniture Required
Approach when on furniture Required
Disturb while resting or sleeping Required
Approach while eating Required
Touch while eating Required
Take dog food away Required
Take human food away Required
Take water dish away Required
Take away rawhide Required
Take away biscuit or cookie Required
Take away real bone Required

GR = Growl

SL = Snarl/bare teeth

SB = Snap/Bite

NR = No Reaction

NA = Not Applicable

Take away toy or object Required
Approach when dog has an object, toy, or bone Required
Verbally punish Required
Physically punish Required
Visual threat Required
Speak to dog (normal tone) Required
Stare at dog Required
Bend over dog Required
Push on dog’s shoulders or back Required
Approach dog when near spouse Required
Enter room Required
Leave room Required
Reach toward dog Required
Leash restraint Required
Collar restraint Required
Scruff restraint Required
Put leash on or take off Required
Put collar on or take off Required
Bathe dog Required

GR = Growl

SL = Snarl/bare teeth

SB = Snap/Bite

NR = No Reaction

NA = Not Applicable

Towel dog Required
Groom or brush dog Required
Dog at groomer’s Required
Trim nails Required
Leash or collar correction Required
Response to "sit" command Required
Response to "down" command Required
Dog at veterinary clinic Required
Unfamiliar adult enters house or yard Required
Unfamiliar child enters house or yard Required
Familiar adult enters house or yard Required
Familiar child enters house or yard Required
Response to toddlers or babies Required
Dog in car at tollbooths or gas stations Required
Unfamiliar adult approaches owner, dog on leash Required
Unfamiliar child approaches owner, dog on leash Required
Dog in house, sees people outside Required
Response to other dogs while on leash Required
Response to other dogs while off leash Required

Where are you on a scale of 1 to 5 as follows?

Please choose the answer that best describes your situation:

For Aggression towards People

(Skip this section if aggression towards people is not the problem)

Please answer Yes or No to these characteristics of your dog's aggressive behavior:

Attacks are sudden and surprising
Episodes appear unprovoked
The dog is abruptly docile after an episode
The dog appears "sorry" afterwards
The dog appears disoriented afterwards
Episodes are associated with a "glazed" or "absent" expression
I can usually tell what will set off my dog
The aggressive behavior is new and uncharacteristic
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