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: Name Preferred local pharmacy: Phone#Preferred local pharmacy: Fax# Basic Canine InformationCanine’s name:* Age: Breed: Color: Gender: Male Female Spayed or neutered: Spayed Neutered Age when performed: Weight: lbs or Kg Date and age when acquired (if known): Date MM slash DD slash YYYY Age Source: Breeder Shelter Stray Rescue Other: Reason for obtaining this dog :Litter size (if known): Age when weaned (if known): Raised indoors or outside (if known): Indoors Outside Describe your dog's personality:Has your dog been bred? Yes No If 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? Yes No Are you the dog’s first owner? Yes No Veterinarian Notes:Canine Medical History *Please ensure that we have all your pet's medical recordsFamily veterinarian/Clinic name PhonePrimary veterinarian: Clinic name: PhoneFax: Date of last veterinary visit: MM slash DD slash YYYY The most recent set of vaccinations received and date ( select all that apply ) :Vaccine Date MM slash DD slash YYYY Vaccine Date MM slash DD slash YYYY Vaccine Date MM slash DD slash YYYY Other: Date MM slash DD slash YYYY Date wormed: MM slash DD slash YYYY Referred by: Provide medical history (infection/surgeries) and prescribed treatment: History Treatment: History Treatment: History Treatment: History Treatment: 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?Drinking Yes No If YES please describe:Eating Yes No If YES please describe:Details: Details: Have you noticed any of the following? Coughing Sneezing Vomiting Diarrhea Has your dog ever been treated for its behavior in the past? If so, describe the treatment and medication (if applicable): Yes No If so, describe treatmentMedications : Dose : Medications : Dose : Medications : Dose : Medications : Dose : Does your dog have seizures or has it ever had any seizures? Yes No Veterinarian Notes:Current Human Household MembersYourselfAge: Occupation: Other Household PetsHave you owned dogs previously? Yes No Have you owned this breed of dogs previously? Yes No Have you owned other pets previously? Yes No Current pets in the household : Type and breed Name Age Spayed or neutered Yes No Relationship with dog (fight, play, avoid) Training Has your dog ever attended training classes? Yes No If so, provide details (where, when, age, handler):What types of training techniques were used? How well did your dog do in class? Very well Average Poor If you were asked to leave, explain why: How would you rate your dog’s learning ability? Good Average Poor What tasks does your dog perform regularly and reliably on cue (e.g. command)? Sit Down Stay Fetch Other Does your dog do tricks? Shake Roll Over Other Does your dog pull when on a lead? Yes No Sometimes Is your dog more obedient in some places than in others? Yes No If so, provide details: Is your dog more obedient with some people than with others? Yes No If 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: Dry Canned Both Brand(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)? Yes No If so, provide details: Describe your dog’s appetite: Good Average Poor At what speed does it typically eat? Fast Slow Do you have to be present for your dog to eat? Yes No What 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? Yes No If so, provide details Veterinarian 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? Yes No If yes, how often and have you any idea why? How often When 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? Yes No If the yard is fenced, what type of material is used? Vinyl Wood Chain Link Other Does your dog run the fence-line barking? Yes No If yes, at whom does it bark? At other dogs At people Does your dog enjoy exploring on its own? Always Sometimes Never What type of exercise does your dog receive? Walk Run Agility training Other If other, provide details: Is this done on or off a lead? On lead Off lead Provide details of the frequency of exercise: Is there any specific time devoted to play or training on a daily basis? Yes No Does your dog play games with you or other family members? Yes No If yes, provide details: Who initiates play? Dog Family members UntitledWhat types of toys does your dog play with? Choose all that apply Select All Balls Bones Ropes Frisbee Other If other, provide details: Where does your dog stay during the day when no one is home? Crate Specified room Free run (in house) Free run (in fenced yard) Doggie daycare/camp What does your dog do as you prepare to depart? Details:Does your dog bark or whine when you leave? Yes No Typically, 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? Vocalizing Destructive behaviors Urination Defecation What does your dog do during family meals? Have there been any changes in your household routine (e.g., new baby, change in working hours)? Yes No If yes, provide details List 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? Apartment House Condo Townhome Other If 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/grooming Yes No N/A Petting or hugging Yes No N/A Disturbed when resting Yes No N/A Disciplining Yes No N/A Walking on the lead Yes No N/A Taking food away Yes No N/A Taking other objects away Yes No N/A Adult owner #2 Name: Handling/grooming Yes No N/A Petting or hugging Yes No N/A Disturbed when resting Yes No N/A Disciplining Yes No N/A Walking on the lead Yes No N/A Taking food away Yes No N/A Taking other objects away Yes No N/A Children Handling/grooming Yes No N/A Petting or hugging Yes No N/A Disturbed when resting Yes No N/A Disciplining Yes No N/A Walking on the lead Yes No N/A Taking food away Yes No N/A Taking other objects away Yes No N/A Any other specific individual Name: Handling/grooming Yes No N/A Petting or hugging Yes No N/A Disturbed when resting Yes No N/A Disciplining Yes No N/A Walking on the lead Yes No N/A Taking food away Yes No N/A Taking other objects away Yes No N/A Veterinarian 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? Yes No If yes, provide details: Does your dog display aggression (e.g., growling, snarling, snapping, biting) to visitors inside your home? Yes No If yes, provide details: Does your dog display aggression (e.g., growling, snarling, snapping, biting) to visitors outside your home? Yes No If yes, provide details: Has your dog ever bitten or attacked anyone? Yes No If 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 men Inside Details: Outside Details: Familiar women Inside Details: Outside Details: Familiar children Inside Details: Outside Details: Unfamiliar men Inside Details: Outside Details: Unfamiliar women Inside Details: Outside Details: Unfamiliar children Inside Details: Outside Details: Familiar dogs Inside Details: Outside Details: Unfamiliar dogs Inside Details: Outside Details: Other animals (e.g., cats, squirrels) Inside Details: Outside Details: Crowds and busy areas Inside 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? Yes No Specify whom or what is the target: Is your dog protective of parts of its body (e.g., ears, mouth, feet)? Yes No If yes, specify which regions: Does your dog lick or chew itself more than you would expect? Yes No Does your dog display any reaction to loud noises such as thunderstorms or fireworks? Yes No If yes, give details: Are there any other behaviors that you find objectionable, feel you should mention, or wish to discuss? Yes No If 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? Chronic Intermittent Where 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? Home Away Both If the problem is destructive behavior, does it occur when you are home and/or away? Home Away Both Additional details about the problem: Is there any legal action pending because of this dog’s behavior? Yes No If 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: Yes No Details of punishment : Was there a bite wound Puncture Tear Describe the previous three incidents prior to the most recent incident:How frequently does this type of incident occur? Several times a day Daily Several times a week Weekly Monthly Other Does this problem occur when the dog is left alone? Always Sometimes Never Does this problem occur when family members are present? Always Sometimes Never What has been done to correct the problem? Is the problem getting better or worse? Better Worse No change Do you suspect any cause? Veterinarian Notes:Relationship with CanineHow would you describe your own and your family’s relationship with this dog? Adult owner #1 Adult owner #2 Children What are your own and your family’s feelings about the dog’s present behavior? Adult owner #1 Adult owner #2 Children What 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:CAPTCHAUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitled First Choice Second Choice Third Choice Untitled
