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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?

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

GR = Growl

SL = Snarl/bare teeth

SB = Snap/Bite

NR = No Reaction

NA = Not Applicable

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

GR = Growl

SL = Snarl/bare teeth

SB = Snap/Bite

NR = No Reaction

NA = Not Applicable

Towel dog
Groom or brush dog