• This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 10 years for smaller ones) so that we can assess changes associated with aging. If your dog is not elderly or you have no complaints that could be associated with age, you do not have to complete this form. If you are uncertain, please complete the form.
  • 5. Assessment of Bowel Control (select appropriate answer if this occurs)




  • Aggression Questionnaire

    KEY: NR=No reaction; S=Snarl (noise); L=Lift lip (can see corner teeth); B=Bark (aggressive, not an alerting bark); G=Growl (not a play growl); SP=Snap (no connection with skin); BT=Bite (connects with skin, regardless of damage) ; WD=Withdraw or avoid; NA=Not applicable (animal has never been in that situation)
    This screen can be used in three ways:
    • To note the presence or absence, at any time, of any of the behaviors
    • By the clients to keep as a log about the baseline behavior, noting how many times the behavior occurs, given the number of times it is attempted, per unit time (i.e., per week)
    • To keep a log about frequencies of the occurrence behaviors, given the number of times the circumstance has been encountered, at different intervals during treatment so that these numbers can be compared with those in (2)
    Please note if the reaction is consistent in style, or only directed toward one person, or only present in one restricted circumstance. If using this screen only for the first use, note if the dog has been worsening in intensity or frequency in any category.



  • 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

  • Obedience class
  • Private trainer
  • Board certified behaviorist
  • Consult your vet
  • Non-vet 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.

  • Stare at or "stare down"
  • Grab by jowls and shake
  • Get an additional dog as a companion for this one
  • Step on leash or choke collar and force down
  • Blow in nose or face
  • Buy different types of dog toys (e.g., Kongs, etc.)
  • Metal choke collar
  • Prong collar
  • Haiti, head collar, or Gentle Leader
  • Harness
  • No pull or Sporn harness
  • Martingale collar
  • Electronic or shock collar controlled by owner
  • Electronic or shock collar- remote control or bark activated
  • Citronella collar
  • Throw a tin or can of pennies
  • Whistle
  • Hit dog with hand
  • Knee dog in chest / belly
  • Kick dog
  • Bite dog
  • "Alpha roll" [hold spread eagle on back]
  • "Dominance down" [hold down on side, legs extended, head flat]
  • Growl at dog
  • Yell or scream at dog
  • Long down
  • Sit and wait
  • “Time out" [if you do this let us know where and how, and for how long]
  • Praise for good behavior
  • Crate
  • Kennel outdoors
  • Fenced yard
  • Invisible fence
  • Isolate somewhere in house
  • Pop and jerk leash
  • Yank or pull on leash
  • Muzzle
  • Increase exercise
  • Increase play
  • Give treats for good behavior
  • Shove dog's nose/face into urine, feces, or destruction
  • Use scat mats or other electronic avoidance systems
  • Calming cap
  • Thundershirt or Anxiety Wrap
  • Doggies or eyeshades
  • Anything else that was recommended or tried?