Canine Consultation Questionnaire Owner InformationName:*Address Street Address City State / Province / Region Home Phone*Cell Phone*Employer’s name:Employer’s Address Street Address City State / Province / Region ZIP / Postal Code Work PhoneEmail* Preferred local pharmacy:Preferred local pharmacy: NamePreferred local pharmacy: Phone#Preferred local pharmacy: Fax#Basic Canine InformationCanine’s name:*Age:Breed:Color:Gender:MaleFemaleSpayed or neutered:SpayedNeuteredAge when performed:Weight: lbs or KgDate and age when acquired (if known): Date Date Format: MM slash DD slash YYYY AgeSource:BreederShelterStrayRescueOther:Reason for obtaining this dog :Litter size (if known):Age when weaned (if known):Raised indoors or outside (if known):IndoorsOutsideDescribe your dog's personality:Has your dog been bred?YesNoIf so, at what age?How much interaction did the puppy have with people in the first year of life?What method of house training was used?Your reaction to mistakes during house training:Was there any interaction with other puppies and dogs? If so, provide details:Did your dog attend puppy parties?YesNoAre you the dog’s first owner?YesNoVeterinarian Notes:Canine Medical History *Please ensure that we have all your pet's medical recordsFamily veterinarian/Clinic namePhonePrimary veterinarian:Clinic name:PhoneFax:Date of last veterinary visit: Date Format: MM slash DD slash YYYY The most recent set of vaccinations received and date ( select all that apply ) :VaccineDate Date Format: MM slash DD slash YYYY VaccineDate Date Format: MM slash DD slash YYYY VaccineDate Date Format: MM slash DD slash YYYY Other:Date Date Format: MM slash DD slash YYYY Date wormed: Date Format: MM slash DD slash YYYY Referred by:Provide medical history (infection/surgeries) and prescribed treatment: HistoryTreatment:HistoryTreatment:HistoryTreatment:HistoryTreatment:Current/ regular medications (Such as allergy, heartworm, herbal, over the counter, pain medication, supplements, topical flea and tick treatment ) :Medication :Dose :Route :Frequency given :Medication :Dose :Route :Frequency given :Medication :Dose :Route :Frequency given :Medication :Dose :Route :Frequency given :Has there been any change in the following?DrinkingYesNoDetailsEatingYesNoDetailsDetails:Details:Have you noticed any of the following?CoughingSneezingVomitingDiarrheaHas your dog ever been treated for its behavior in the past? If so, describe the treatment and medication (if applicable):YesNoIf so, describe treatmentMedications :Dose :Medications :Dose :Medications :Dose :Medications :Dose :Does your dog have seizures or has it ever had any seizures?YesNoVeterinarian Notes:Current Human Household MembersYourselfAge:Occupation:Other Household PetsHave you owned dogs previously?YesNoHave you owned this breed of dogs previously?YesNoHave you owned other pets previously?YesNoCurrent pets in the household : Type and breedNameAgeSpayed or neuteredYesNoRelationship with dog (fight, play, avoid)Training Has your dog ever attended training classes?YesNoIf so, provide details (where, when, age, handler):What types of training techniques were used?How well did your dog do in class?Very wellAveragePoorIf you were asked to leave, explain why:How would you rate your dog’s learning ability?GoodAveragePoorWhat tasks does your dog perform regularly and reliably on cue (e.g. command)?SitStayDownFetchOtherDoes your dog do tricks?ShakeRolloverDoes your dog pull when on a lead?YesNoSometimesIs your dog more obedient in some places than in others?YesNoIf so, provide details:Is your dog more obedient with some people than with others?YesNoIf so, provide details:How do you correct your dog when he/she misbehaves?What types of training aids have you used (e.g., pinch collar, prong collar, electric shock)?Veterinarian Notes :Diet and Feeding Habits: Type(s) of food:DryCannedBothBrand(s) ( e.g., Nutro, Eukanuba, Alpo ) :Who is primarily responsible for the feeding? Name:How much food is given? Quantity of food:At what approximate time(s) of day is food given? Time of day:Where is the dog fed (physical location)?Where is the dog fed in relation to other dogs in the household?Is the dog protective of its food (e.g., does it growl, snap, or bite)?YesNoIf so, provide details:Describe your dog’s appetite:GoodAveragePoorAt what speed does it typically eat?FastSlowDo you have to be present for your dog to eat?YesNoWhat are your dog’s favorite foods?How many water bowls are provided?How much water does your dog drink in a day (in pints or liters)?Do you add any supplements to your dog’s diet?YesNoIf so, provide detailsVeterinarian Notes:Daily ActivitiesWhere does your dog sleep?If it sleeps on your bed, who invites it up?When does your dog get up in the morning?Does your dog ever wake you at night?YesNoIf yes, how often and have you any idea why? How oftenWhen does your dog get to go outside and how long does it like to stay out for?How does your dog ask to go outside?Does your dog roam free in the yard?YesNoIf the yard is fenced, what type of material is used?VinylWoodChain LinkOtherDoes your dog run the fence-line barking?YesNoIf yes, at whom does it bark?At other dogsAt peopleDoes your dog enjoy exploring on its own?AlwaysSometimesNeverWhat type of exercise does your dog receive?WalkRunAgility trainingOtherIf other, provide details:Is this done on or off a lead?On leadOff leadProvide details of the frequency of exercise:Is there any specific time devoted to play or training on a daily basis?YesNoDoes your dog play games with you or other family members?YesNoIf yes, provide details:Who initiates play?DogFamily membersWhat types of toys does your dog play with?BallsBonesRopesFrisbeeOtherIf other, provide details:Where does your dog stay during the day when no one is home?CrateSpecified roomFree run (in house)Free run (in fenced yard)Doggie daycare/campWhat does your dog do as you prepare to depart? Details:Does your dog bark or whine when you leave?YesNoTypically, how long is your dog left alone without human company on any given day?Does your dog ever vocalize, engage in destructive behaviors, urinate, or defecate while you are away from home?VocalizingDestructive behaviorsUrinationDefecationWhat does your dog do during family meals?Have there been any changes in your household routine (e.g., new baby, change in working hours)?YesNoIf yes, provide detailsList the five things your dog likes the most (e.g., specific activities, food, toys)Veterinarian Notes:Interaction With Family MembersWhat type of home do you have?ApartmentHouseCondoTownhomeOtherIf other, provide details:To which areas of your home does your dog have access?Reaction to handling: Does your dog exhibit any aggression in the following circumstances? This can include growling, snarling, lunging, nipping, snapping, showing teeth, or even biting. If biting occurs, please specify whether tear puncture, or bruising is involved: Fill out the following tables depicting your dog’s typical reaction: In each box, describe the type of aggression (e.g., growling, snarling) that may be exhibited in each situation, even if it does not occur every time. Adult owner #1 Name:Handling/groomingYesNoN/APetting or huggingYesNoN/ADisturbed when restingYesNoN/ADiscipliningYesNoN/AWalking on the leadYesNoN/ATaking food awayYesNoN/ATaking other objects awayYesNoN/AAdult owner #2 Name:Handling/groomingYesNoN/APetting or huggingYesNoN/ADisturbed when restingYesNoN/ADiscipliningYesNoN/AWalking on the leadYesNoN/ATaking food awayYesNoN/ATaking other objects awayYesNoN/AChildrenHandling/groomingYesNoN/APetting or huggingYesNoN/ADisturbed when restingYesNoN/ADiscipliningYesNoN/AWalking on the leadYesNoN/ATaking food awayYesNoN/ATaking other objects awayYesNoN/AAny other specific individual Name:Handling/groomingYesNoN/APetting or huggingYesNoN/ADisturbed when restingYesNoN/ADiscipliningYesNoN/AWalking on the leadYesNoN/ATaking food awayYesNoN/ATaking other objects awayYesNoN/AVeterinarian Notes:Interaction With OthersHow does your dog behave when visitors come to the house (e.g., barking, door charging)?Is the behavior different towards familiar and unfamiliar people?YesNoIf yes, provide details:Does your dog display aggression (e.g., growling, snarling, snapping, biting) to visitors inside your home?YesNoIf yes, provide details:Does your dog display aggression (e.g., growling, snarling, snapping, biting) to visitors outside your home?YesNoIf yes, provide details:Has your dog ever bitten or attacked anyone?YesNoIf yes, how many times?Are there any regular visitors to the home? If so, please provide the information requested: Name:Purpose :Time and days :Dog’s reaction:What is your dog’s response to frequent, occasional, and rare visitors? Frequent visitors :Occasional visitors:Rare visitors :Dog’s reaction to :Inside the home :Outside the home :Familiar menInside Details:Outside Details:Familiar womenInside Details:Outside Details:Familiar childrenInside Details:Outside Details:Unfamiliar menInside Details:Outside Details:Unfamiliar womenInside Details:Outside Details:Unfamiliar childrenInside Details:Outside Details:Familiar dogsInside Details:Outside Details:Unfamiliar dogsInside Details:Outside Details:Other animals (e.g., cats, squirrels)Inside Details:Outside Details:Crowds and busy areasInside Details:Outside Details:Other dogs On lead:Inside Details:Outside Details:Other dogs Off lead:Inside Details:Outside Details:Veterinarian Notes :Other BehaviorsDoes your dog show inappropriate mounting or other sexual behavior?YesNoSpecify whom or what is the target:Is your dog protective of parts of its body (e.g., ears, mouth, feet)?YesNoIf yes, specify which regions:Does your dog lick or chew itself more than you would expect?YesNoDoes your dog display any reaction to loud noises such as thunderstorms or fireworks?YesNoIf yes, give details:Are there any other behaviors that you find objectionable, feel you should mention, or wish to discuss?YesNoIf yes, describe these:Veterinarian Notes:The Current ProblemDescribe the problem you are currently experiencing with your dog :How old was the dog when the problem began?Is this a chronic (constant) or intermittent problem?ChronicIntermittentWhere does the problem commonly occur?With whom does it occur?How often does it occur?If the problem is house soiling, does it occur when you are home and/or away?HomeAwayBothIf the problem is destructive behavior, does it occur when you are home and/or away?HomeAwayBothAdditional details about the problem:Is there any legal action pending because of this dog’s behavior?YesNoIf yes, please explain in detail:Veterinarian Notes:Aggression Section ( if applicable )Describe the most recent incident and the setting in which it occurred (be precise) :Where was the dog?Where was everyone else in relation to the dog?What was everyone doing prior to the incident?What was the dog’s body posture (position of ears, tail, face, fur)?What was your reaction or response?What was the dog’s response to your reaction?Was any form of punishment used? If so, give details:YesNoDetails of punishment :Was there a bite woundPunctureTearDescribe the previous three incidents prior to the most recent incident:How frequently does this type of incident occur?Several times a dayDailySeveral times a weekWeeklyMonthlyOtherDoes this problem occur when the dog is left alone?AlwaysSometimesNeverDoes this problem occur when family members are present?AlwaysSometimesNeverWhat has been done to correct the problem?Is the problem getting better or worse?BetterWorseNo changeDo you suspect any cause?Veterinarian Notes:Relationship with CanineHow would you describe your own and your family’s relationship with this dog? Adult owner #1Adult owner #2ChildrenWhat are your own and your family’s feelings about the dog’s present behavior? Adult owner #1Adult owner #2ChildrenWhat is your expectation for change?Under what circumstances would you consider rehoming this dog?Under what circumstances would you consider relinquishing this dog to a shelter or rescue?Under what circumstances would you consider euthanasia?Veterinarian Notes:Video RecordingsVideo recordings of the specific problem behaviors are extremely helpful for verifying your descriptions. Never place any person or animal in danger in order to obtain video information. Feel free to bring the video recordings with you (on your phone, tablet, laptop, etc.) to your consultation. Please do not email videos ahead of time. Video number :Describe the scenario seen in the video :Veterinarian Notes:Video Notes:CAPTCHA
