Dog Behavior Questionnaire

Step 1 of 15

Owner Information

Owner's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Preferred Phone(Required)

I consent to receive SMS text messages from Liberty Pet Hospital. Msg & data rates may apply. Reply STOP to opt-out.(Required)

Yes

Secondary Phone

Email(Required)

Patient Information

Pet's Name(Required)

Breed(Required)

Age/Date of Birth(Required)

Sex(Required)

Male

Male (neutered)

Female

Female (spayed)

Home Environment

Please list the people, starting with yourself, living in your household:

Name(Required)

First Last

Age(Required)

Sex(Required)

Relationship (i.e. self, spouse, etc.)(Required)

Occupation

Average number of hours away from home per day(Required)

Quality of relationship with patient(Required)

Add a second person?(Required)

Yes

Hidden

Second Person

Name(Required)

First Last

Age(Required)

Sex(Required)

Relationship (i.e. self, spouse, etc.)(Required)

Occupation

Average number of hours away from home per day(Required)

Quality of relationship with patient(Required)

Add a third person?(Required)

Yes

Hidden

Third Person

Name(Required)

First Last

Age(Required)

Sex(Required)

Relationship (i.e. self, spouse, etc.)(Required)

Occupation

Average number of hours away from home per day(Required)

Quality of relationship with patient(Required)

Add a fourth person?(Required)

Yes

Hidden

Fourth Person

Name(Required)

First Last

Age(Required)

Sex(Required)

Relationship (i.e. self, spouse, etc.)(Required)

Occupation

Average number of hours away from home per day(Required)

Quality of relationship with patient(Required)

Home Environment (cont.)

Please list all the animals in the household in the sequence they were obtained:

Pet's Name(Required)

Species(Required)

Breed(Required)

Sex(Required)

Male

Male (neutered)

Female

Female (spayed)

Age Obtained(Required)

Age Now(Required)

Quality of relationship with patient we are seeing(Required)

Add a second pet?(Required)

Yes

Hidden

Pet #2

Pet's Name(Required)

Species(Required)

Breed(Required)

Sex(Required)

Male

Male (neutered)

Female

Female (spayed)

Age Obtained(Required)

Age Now(Required)

Quality of relationship with patient we are seeing(Required)

Add a third pet?(Required)

Yes

Hidden

Pet #3

Pet's Name(Required)

Species(Required)

Breed(Required)

Sex(Required)

Male

Male (neutered)

Female

Female (spayed)

Age Obtained(Required)

Age Now(Required)

Quality of relationship with patient we are seeing(Required)

Add a fourth pet?(Required)

Yes

Hidden

Pet #4

Pet's Name(Required)

Species(Required)

Breed(Required)

Sex(Required)

Male

Male (neutered)

Female

Female (spayed)

Age Obtained(Required)

Age Now(Required)

Quality of relationship with patient we are seeing(Required)

Behavioral History

Please describe your dog’s primary behavior problems and other problems you would like addressed. Please include dates and details of recent incidents and the age at which the problem began.(Required)

Background Information

How long have you had your dog?(Required)

How old was your dog when you first acquired them?(Required)

Where did you get your dog?(Required)

Has this dog had other owners?(Required)

Yes

If yes, how many?(Required)

Why was the dog given up by the previous owners?(Required)

Why did you acquire this dog?(Required)

Interaction with Other Animals

What is your dog’s relationship with the other animals in your household?(Required)

What is your dog’s response to unfamiliar dogs?(Required)

Does your dog interact with other dogs, besides those in your household, on a regular basis? If so, when and where?(Required)

What is your dog’s response to cats or other small animals outside your household?(Required)

Interaction with Household People

Please tell us if there is any aggression in the following circumstances to any members of your household. This may include growling, showing teeth, lunging, nipping, snapping, or biting. Please select the corresponding option(s) if there has been any aggression to any family member(s) in each circumstance or "N/A" if the circumstance does not apply.

Petting or reaching for dog(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Hugging or kissing dog(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Bending over or staring at dog(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Bathing, grooming or toweling dog(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Disturbing dog when resting(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Pushing or calling dog off furniture(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Giving verbal or physical corrections(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Approach/interact when dog is eating(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Approach/interact when dog has bone or other chew item(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Putting on leash or collar(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Lifting dog(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Interaction with Non-Household People

Please tell us if there is any aggression in the following circumstances to any person who is not a member of your household. This may include growling, showing teeth, lunging, nipping, snapping, or biting. Please select the corresponding option(s) if there has been any aggression in each circumstance or "N/A" if the circumstance does not apply.

Petting or reaching towards dog(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Bending over or staring at dog(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Entering your house or yard(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Enter/exit any room in your home(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Passing when dog is on leash(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Passing when dog is in the car(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Interacting w/dog on leash(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Interacting w/dog away from home(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Putting on leash or collar(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

Running/jogging/biking(Required)

Female adults

Male adults

Children

Specific person

N/A

Please provide details(Required)

What is your dog’s response to frequent visitors?(Required)

What is your dog’s response to occasional visitors?(Required)

What is your dog’s response to rare visitors?(Required)

What is your dog’s response to repair/delivery persons?(Required)

Fears & Anxieties

Please mark the behaviors your dog exhibits for each of the below circumstances. Check all that apply.

Dog is home with family member(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Dog is home alone(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Dog is home alone with another pet(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Dog is home with family but separated from family members(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Dog is home alone confined to a crate(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Dog is at veterinary office(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Dog is at groomer’s(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Fireworks(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Thunderstorms(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Loud noises(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Flashes of light(Required)

Defecate

Urinate

Salivate

Dilate pupils

Tremble

Tucks tail

Hide

Escape

Destroy

Vocalize

N/A

Please list any specific stimuli (i.e., men, umbrellas, traffic noises) your dog seems to be afraid of:(Required)

Treatment

This questionnaire is designed to help us evaluate any role previous treatment may play in either your dog’s problems or in their  resolution. Please check the items below that were recommended and/or attempted. If your dog responded aggressively or with  fear as a result of the use of any of these methods please provide details of the outcome.(Required)

Stare at or "stare down"

Grab by jowls/scruff +/- shake

Shake or throw a can

Step on leash or choke collar and force down

"Time out"

Metal choke or pronged collar

Water pistol/spray

Halti or Gentle Leader head collar

No-pull harness (i.e. Easy Walk)

Bark or remote-activated shock collar

Invisible/electric fence (inside or out)

Citronella spray collar

Forced exposure to frightening stimuli

Knee dog in chest/belly for jumping

Hit or kick dog

Growl at dog

"String up" or hang by leash and collar

Rub dog’s nose/face into urine, feces or destruction

Tie or tether on short lead hooked to wall or floor

Yell "no" at dog

"Alpha roll" (hold on back, put down on back)

"Dominance down" (hold on side, legs extended, head flat)

Crate

Sit or lie down for extended period

Agility or other sport activity

Use of food or puzzle toys (Kongs, etc.)

Praise for good behavior

Food rewards for good behavior

Kennel outdoors

Tether/tie out on a line in yard

Use of muzzle at home or on walks

Teach dog "look" or "watch me"

Increase play/exercise

Clicker training

Avoidance of stimuli that trigger fear or aggression

Feed meals by hand

Remove food bowl while eating

Pheromones (DAP, Comfort Zone)

N/A

Where, when, and how long do you put your dog in "time out"?(Required)

Please provide details of the outcome of each method selected(Required)

Environment

What type of area do you live in (urban, suburban, etc.)?(Required)

What type of home do you live in (studio, apartment, house)?(Required)

Do you have a yard?(Required)

Yes

If so, what type of fence do you have?(Required)

What is the height of your fence?(Required)

Has your household changed since acquiring your dog?(Required)

Yes

If so, how?(Required)

Daily Schedule

How many times is your dog walked on a leash per day?(Required)

Zero

Once

Twice

Three times

Four time

Five times

Six times

Seven times

Eight times

More than eight times

What is the average length of each leash walk (please do not include yard time)?(Required)

How many times is your dog let out in the yard each day?(Required)

Zero

Once

Twice

Three times

Four time

Five times

Six times

Seven times

Eight times

More than eight times

On average, for how long?(Required)

Does someone go out with the dog?(Required)

Yes

How many hours per day does your dog spend OUTDOORS unsupervised?(Required)

Does your dog have access to the outside through a dog door?(Required)

Yes

Where is your dog when home alone? (i.e. confined to a room or crate, loose in the house, outdoors, etc.)(Required)

Do you limit your dog’s access to any part of the house when you are home? If so, please explain.(Required)

Where is your dog when you have guests? Please indicate whether this is by choice, or whether you put them there.(Required)

How do you play with your dog?(Required)

Does your dog ever eliminate in the house?(Required)

Yes

If so, do they:(Required)

Urinate

Defecate

Both

Does the elimination occur primarily:(Required)

When you are home

When the dog is home alone

Both

How does your dog behave as you prepare to leave?(Required)

How does your dog behave when you return?(Required)

Where does your dog sleep at night?(Required)

What is a typical day (24 hours) in the pet’s life like?  Please start with where the pet is when you wake up in the morning. Please indicate approximate times.(Required)

Diet & Feeding

What do you feed your dog? (Please be specific, i.e. brand name, canned vs. dry)(Required)

How many meals is your dog fed each day?(Required)

Where is your dog’s food bowl?(Required)

Please describe the meal routine including if other animals eat at the same time, describe the arrangement (e.g. same room, separate rooms, etc.).(Required)

Does your dog finish each meal?(Required)

Yes

Does someone have to be present for your dog to eat?(Required)

Yes

Does your dog have any food allergies or diet restrictions?(Required)

Yes

If so, please specify(Required)

Is water available to your dog 24 hours a day?(Required)

Yes

If no, why not?(Required)

Medical History

At what age was your dog neutered/spayed (if applicable)?

Reason for spay/neuter

If your dog is not neutered has he/she ever been bred?

Yes

Unsure

Are you planning to breed your dog?

Yes

Unsure

Is your pet currently receiving heartworm and flea/tick prevention?(Required)

Yes

If so, please list the type(Required)

Do you ever use the following medications/treatments for your dog?(Required)

Tramadol (pain medication)

Preventic collar

None of the above

Is your pet on any medications at this time?(Required)

Yes

If so, please specify(Required)

Medical Problems:  Please list any previously diagnosed medical problems and how they were treated (please include date, diagnosis, treatment  (including medications and dosage), and outcome)

Please list any BEHAVIORAL medications/supplements you have administered to your pet (please include date, treatment, and outcome)

Training

Has your dog ever attended a training class or had a trainer come to your home?(Required)

Yes

If so, please give details (when, where, age of dog, who trained dog)(Required)

What method of training was used (i.e. clicker training, leash corrections, special collars, etc.)(Required)

Name of Trainer(Required)

Have you done any specialized training with your dog (i.e. agility, tracking, fly ball)?(Required)

Yes

How did your dog perform in training class?(Required)

Does your dog have any titles/awards?(Required)

Have you consulted any other behavior specialists prior to your appointment with us?(Required)

Yes

If so, who?(Required)

What tasks will your dog reliably perform on verbal cue (check all that apply)?(Required)

Sit

Lie down

Come

Wait

Stay

Heel (not pulling)

Watch

Fetch

Drop it

Other

None of the above

If other, please specify(Required)

How did you house train your dog?(Required)

Did you have any difficulties house training your dog? If so, please describe.(Required)

Have you ever used a crate?(Required)

Yes

If yes, do you continue to use it?(Required)

Never

Rarely

Sometimes

Frequently

Where is the crate located?(Required)

Micellaneous

Does your dog ever mount people, dogs or objects?(Required)

Yes

If so, who/what and how often?(Required)

Does your dog ever lick people, himself, or inanimate objects excessively?(Required)

Yes

If so, who/what and how often?(Required)

Is your dog sensitive about having certain body parts touched or handled (especially ears and feet)?(Required)

Yes

If yes, which parts?(Required)

Why have you kept the dog despite its behavior problem?(Required)

Has the frequency or intensity of the behavior changed since the problem started?(Required)

Yes

If so, how and when?(Required)

How do you react when your dog shows problem behaviors?(Required)

How does your pet respond to your reaction?(Required)

Have you read any dog training books?(Required)

Yes

If so, please list them(Required)

Bite History

If your dog has ever bitten anyone, please list the total number of bites and description of each incident:

Please list the number of bites that broke skin:

Please list the number of bites reported to public health authorities, and to whom: (i.e. local authorities, hospital, humane society, etc.):

Was there legal action taken against you as a result of the bite(s)?

Yes

Have you considered finding another home for this dog?

Yes

Have you considered euthanasia (putting your dog to sleep)?

Yes

Goals

What are your goals for your appointment with us?(Required)

Anything else you would like to add about your pet’s behavior?

Phone

This field is for validation purposes and should be left unchanged.