Stereotypical and Ritualistic Behavior HistoryClient Name* First Last Name*This section of the history form is to be completed only if your dog is showing any repetitive, ritualistic behaviors that you find troublesome or about which you are concerned. If your dog is not doing this, you do not have to complete this form. The first section focuses on a description and categorization of your dog's behavior(s) The second section focuses on patterns of behaviors. Please indicate the appropriate answer (YES/NO/UNCERTAIN) for each question. 1. Which of the following categories below fits your dog's behavior? Tick as many categories that apply to the dog's behavior. Then tick the best description that relates to the selected behavior. Grooming Hallucinatory Consumptive Locomotory Vocalization Grooming Chewing self Biting self Licking self Plucking hair from self Trimming hair on self Sucking self Continuously doing any of these to another individual Other OtherHallucinatory Staring and attending to things that are not there Tracking things that are not there Pouncing on or attacking things that are not there Other, please explain: Other, please explainConsumptive Consuming rocks Consuming dirt or soil Consuming other objects Licking or gulping air Eating, licking, sucking, or chewing wool or fabric , rugs, furniture, et cetera Other: OtherLocomotory Circling/ spinning Tail-chasing Freezing Other: OtherVocalization Rhythmic barking Howling Growling Other: Other2. Was there a change in the household or an event associated with the development of the behavior? Yes No Uncertain Comment3. Is there any time of day when the behavior seems more or less intense? Yes No Uncertain Comment4. Is there a person or another pet in the presence of whom the behavior seems more intense? Yes No Uncertain Comment5. Does the dog respond to its name or seem aware of its surroundings while in the midst of the behavior? Yes No Uncertain Comment6. Is the dog aware that you are calling him/her? Yes No Uncertain Comment7. Can you convince the dog to stop the behavior by calling him/her? Yes No Uncertain Comment8. Can you convince the dog to stop the behavior by using physical restraint? Yes No Uncertain Comment9. Is there a location in which the dog prefers to perform the behavior? Yes No Uncertain Comment10. Does any event or behavior routinely occur immediately before the behavior begins? Yes No Uncertain Comment11. Does any event or behavior routinely occur immediately after the behavior ceases? Yes No Uncertain Comment12. Has the dog's general behavior changed in any way since the onset of the atypical behavior (i.e., the dog is more or less aloof, aggressive, withdrawn, playful, et cetera)? Yes No Uncertain Comment13. Has the dog's diet recently been changed? Yes No Uncertain Comment14. Did anyone else in the dog's family exhibit these or similar behaviors? Yes No Uncertain Comment15. List the kinds of things (i.e., noises, treats, toys), if any, that will interrupt the behavior once it has started.16. For ingestion, list what types of objects are consumed. Be as specific as possible-what type of rug or sweater fabric?CAPTCHA
