Telford Veterinary Hospital

Telford Veterinary Hospital

Phone: (215) 721-6989

78 Souderton Hatfield Pike
Souderton, PA 18964

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Basic History Questionnaire For Dogs

Sex of Dog*
MM slash DD slash YYYY
Has this dog been bred?*
If you have not yet bred this dog, do you plan on breeding him or her?*
Has this dog been neutered/spayed?*
Any behavioral changes after neutering/spaying? If so, please explain
Has this pet had other owners?*
Where did you get this pet?*
Does this dog have any physical problems that your veterinarian has noted?*
Is your dog taking any medication for any of the medical problems discussed above? If so, please explain*
Is your dog taking any medication or supplements for behavioral issues? If yes, please explain the type, dose and your pet's response in the comments below*
How is your dog exercised/maintained? This dog is (please check all that apply) :*
How is your dog kept when you leave him or her alone?*
% Inside
% Outside
What kind of a living situation do you have?*
Has your household changed in any of the following ways since acquiring this pet?*
Are any litter mates affected with any behavioral problems? If so, please explain*
What is your dog's obedience school/training history?*
Where does your pet sleep? (Please check all that apply; we know pets move at night.)*
How did the dog do in obedience school/training?
Sit
Stay
Down/ lie down
Wait
Heel
Fetch
Leave it/drop it
Take it
Does your pet have any other commands?
How do they respond to your other commands?
Describe the home situation
Please list the people, including yourself, currently living in the household now?
What are the genders of the people currently living in the household?
What are the ages of the people currently living in the household?
What are the relationships between those currently living in the household? i.e. Mother, Son, Friend
What are the occupations of those currently living in the household?
Please list all the animals (include all pets, even non- dogs) in the household
In what order were the animals obtained?
What species and breeds of animals are they?
What gender are they?
What age were they when obtained?
What age are they now?
Are there any illnesses or behavioral issues?
If your dog has a behavior problem(s), please list them and let us know how much of a problem do you consider the behavior. Please tick relevant degree of severity
Severity
Severity
Severity
For the complaints above, please estimate the frequency of occurrence of the undesirable behavior (percent of time is when that the animal is in a situation and during which undesirable behavior occurs):
Primary Issue Frequency
Secondary Issue Frequency
Tertiary Issue Frequency
Have you considered finding another home for this pet?*
Have you considered euthanasia (putting your pet to sleep)?*
Was there legal action taken as a result of any bite to humans?*
Do you know if the parents engage in similar behaviors as presented animal?*
Does your dog exhibit periodic diarrhea or gastrointestinal distress?*

Separation Anxiety And Noise Phobia/Reactivity Questionnaire


The first set of these questions deals with an "actual absence"-the client actually leaves the house and the dog is either alone or totally without the client. The second set deals with "virtual absence"-the client is home, but not accessible because the door is closed, or the dog is barricaded in another room. The questions are the same for each, but please answer both. Check NO if the dog does not react in the listed circumstance. Check UNKNOWN if you don't know. Check YES if the dog reacts. Please evaluate the extent of the reaction from the list below.

1. Behaviors during an ACTUAL absence

A. Destructive behavior when separated from client
What is the timing of the onset of behaviors (if known)?
B. Urination when separated from client
What is the timing of the onset of behaviors (if known)?
C. Defecation when separated from client
What is the timing of the onset of behaviors (if known)?
D. Vocalization when separated from client.
What is the timing of the onset of behaviors (if known)?
E. Salivation when separated from client.
What is the timing of the onset of behaviors (if known)?

2. Behaviors during a VIRTUAL absence

A. Destructive behavior when separated from client
What is the timing of the onset of behaviors (if known)?
B. Urination when separated from client
What is the timing of the onset of behaviors (if known)?
C. Defecation when separated from client.
What is the timing of the onset of behaviors (if known)?
D. Vocalization when separated from client
What is the timing of the onset of behaviors (if known)?
E. Salivation when separated from client
What is the timing of the onset of behaviors (if known)?

3. Reactions to NOISE

A. Reaction during thunderstorms. Type of response (check all that apply):
Frequency of reaction during thunderstorms
B. Reaction during fireworks. Type of response (check all that apply):
Frequency of reaction during fireworks
C. Reaction during gunshots. Type of response (check all that apply):
Frequency of reaction during gunshots
D. Reaction to other noises. Type of response (check all that apply):
Frequency of reaction to other noises
E. How frequently in terms of weeks do noise events such as thunder, fireworks, or gunshots occur in the dog's environment?
F. Has this dog ever been treated for noise sensitivities or phobias?
G. Does your dog react to other aspects of storms?
a. Wind
b. Darkness
c. Ozone
d. Barometric Pressure
e. Rain

Aggression Questionnaire


Take dog's food dish with food
Take dog's empty food dish
Take dog's water dish
Take food (human) that falls on floor
Take rawhide
Take real bone
Take toy
Take biscuit
Human approaches dog while eating
Dog approaches dog while eating
Human approaches dog while playing with toys
Dog approaches dog while playing with toys
Human approaches/disturbs dog while sleeping
Dog approaches/disturbs dog while sleeping
Step over dog
Push dog off bed/couch
Reach toward dog
Reach over head
Put on leash
Push on shoulders
Push on rump
Towel dry feet when wet
Bathe dog
Groom dog's head
Groom dog's body
Stare at dog
Take muzzle in hands and shake
Push dog over onto back
Stranger knocks on door
Stranger enters room
Dog in car at toll booth
Dog in car at gas station
Dog on leash approached by dog on the street
Dog on leash approached by person on the street
Dog in yard as person passes
Dog in yard as dog passes
Dog in Vet's office
Dog in boarding kennel
Dog at groomers
Dog yelled at
Dog corrected with leash
Dog physically punished or hit
Someone raises their voice to owner in presence of the dog
Someone hugs/touches owner in presence of the dog
Squirrels, cats or small animals approach dog
Bicycles or skateboards
Crying infant
Playing with 2 year old children
Playing with 5 to 7 year old children
Playing with 8 to 11 year old children
Playing with 12 to 16 year old children

Previous Treatment Questionnaire


This questionnaire is designed to help us evaluate any role previous treatment may play in either your dog's problems or in their resolution. We would like you to answer two types of questions. The first set focuses on general, global approaches recommended. The second set, which is a fairly lengthy tick list, focuses on specific actions recommended. Please complete these tables to the best of your ability, and if our lists are not complete, or you feel that an explanation is warranted, please complete the "comment " section at the bottom. Even if you think that your dog is problem-free it would be extraordinarily helpful if you also completed this questionnaire so that we can compare dogs with problems to dogs without problems. Thanks!
1. Global, general approaches recommended
Has someone suggested an Obedience class?
Have you attempted to participate in an Obedience class?
Has someone suggested a Private Trainer?
Have you attempted to use a Private Trainer been?
Has someone suggested a Board certified behaviorist?
Have you attempted to use a Board certified behaviorist?
Has someone suggested consulting your Veterinarian?
Have you consulted your Veterinarian?
Has someone suggested a non-veterinary behavioral consultant?
Have you attempted to use a non-veterinary behavioral consultant?
2. Please select the items below if they were suggested and or attempted. Please let us know who suggested that you try the activity noted, and the outcome if you attempted it.
Suggested to stare at or "stare down"
Attempted to stare or "stare down"
Suggested to grab by jowls and shake
Attempted to grab by jowls and shake
Suggested getting an additional dog as a companion for this one?
Attempted getting an additional dog as a companion for this one?
Suggested to step on leash or choke collar and force down?
Attempted to step on leash or choke collar and force down?
Suggested to blow in nose or face?
Attempted to blow in nose or face?
Suggested to buy different types of dog toys (e.g., Kongs, etc.)?
Attempted to buy different types of dog toys (e.g., Kongs, etc.)?
Suggested to use metal choke collar?
Attempted to use metal choke collar?
Suggested to use a prong collar?
Attempted to use a prong collar?
Suggested to use a Haiti, head collar, or Gentle Leader?
Attempted to use a Haiti, head collar, or Gentle Leader?
Suggested to use a harness?
Attempted to use a harness?
Suggested to use a no-pull or Sporn harness?
Attempted to use a no-pull or Sporn harness?
Suggested to use a Martingale collar?
Attempted to use a Martingale collar?
Suggested to use an electronic or shock collar controlled by owner?
Attempted to use an electronic or shock collar controlled by owner?
Suggested to use an electronic or shock collar- remote control or bark activated?
Attempted to use an electronic or shock collar- remote control or bark activated?
Suggested to use a Citronella collar?
Attempted to use a Citronella collar?
Suggested to try throwing a tin or can of pennies?
Attempted to try throwing a tin or can of pennies?
Suggested to use a Whistle?
Attempted to use a Whistle?
Suggested to hit dog with hand?
Suggested to hit dog with hand?
Suggested to knee dog in chest or belly?
Attempted to knee dog in chest or belly?
Suggested kicking the dog?
Attempted kicking the dog?
Suggested biting the dog?
Attempted biting the dog?
Suggested trying an "Alpha roll" (hold spread eagle on back)?
Attempted trying an "Alpha roll" (hold spread eagle on back)?
Suggested trying a "Dominance down" (hold down on side, legs extended, head flat)?
Attempted trying a "Dominance down" (hold down on side, legs extended, head flat)?
Suggested growling at the dog?
Attempted growling at the dog?
Suggested yelling or screaming at the dog?
Attempted yelling or screaming at the dog?
Suggested trying a long down?
Attempted trying a long down?
Suggested trying sit and wait?
Attempted trying sit and wait?
Suggested trying “Time out"?
Attempted trying “Time out" (where and how, and for how long)?
Suggested trying praise for good behavior?
Attempted trying praise for good behavior?
Suggested to use a crate?
Attempted to use a crate?
Suggested to use an outdoor kennel?
Attempted to use an outdoor kennel?
Suggested to use a fenced-in yard?
Attempted to use a fenced-in yard?
Suggested to use a invisible fence?
Attempted to use an invisible fence?

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Telford Veterinary Hospital

Phone: (215) 721-6989 78 Souderton Hatfield Pike
Souderton, PA 18964

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      • Aggresion Questionnaire
      • Basic History Questionnaire For Dogs
      • Behavioral Assessment Forms
      • Previous Treatment Questionnaire
      • Questionnaire to Evaluate Behaviors of Old Dogs
      • Separation Anxiety and Noise Phobia/Reactivity Questionnaire
      • Stereotypical and Ritualistic Behavior History
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    • Behavioral Consultations
    • Laser Therapy
    • Integrative Medicine
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