Testing 2STEROTYPICAL 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 —————————————————QUESTIONNAIRE TO EVALUATE BEHAVIORS OF OLD DOGSClient Name* First Last Pet's Name*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.1. Locomotory/ambulatory assessment (select only one) No alterations or debilities noted Modest slowness associated with change from youth to adult Moderate slowness associated with geriatric aging Moderate slowness associated with geriatric aging plus alteration or debility in gait Moderate slowness associated with geriatric aging plus some loss of function (e.g., cannot climb stairs) Severe slowness associated with extreme loss of function, particularly on slick surfaces (may need to be carried) Severe slowness, extreme loss of function, and decreased willingness or interest in locomoting (spends most of time in bed) Paralyzed or refuses to move 2. Appetite assessment (may select more than one) No alterations in appetite Change in ability to physically handle food Change in ability to retain food (vomits or regurgitates) Change in ability to find food Change in interest in food (may have to do with their ability to smell) Change in rate of eating Change in completion of eating Change in timing of eating Change in preferred textures 3. Assessment of elimination frequency and “accidents” (select only one) No change in frequency and no "accidents" Increased frequency, no "accidents" Decreased frequency, no "accidents" Increased frequency with "accidents" Decreased frequency with "accidents" No change in frequency, but "accidents" 4. Assessment of Bladder Control (select only one) Leaks urine when asleep, only Leaks urine when awake, only Leaks urine when awake or asleep Full-stream, uncontrolled urination when asleep, only Full-stream, uncontrolled urination when awake, only Full-stream, uncontrolled urination when awake or asleep No leakage or uncontrolled urination, all urination controlled, but in inappropriate or undesirable location No change in urination control or behavior 5. Assessment of Bowel Control (select appropriate answer if this occurs)Defecates when asleep Formed Stool Diarrhea Mixed Defecates without apparent awareness Formed Stool Diarrhea Mixed Defecates when awake but undesirable or inappropriate areas Formed Stool Diarrhea Mixed No changes in bowel control No changes in bowel control 6. Visual acuity-how well do you think the dog sees? (select only one) No change in visual acuity detected – appears to see as well as ever Some change in acuity not dependent on ambient light conditions Some change in acuity dependent on ambient light conditions Extreme change in acuity not dependent on ambient light conditions Extreme change in acuity dependent on ambient light conditions Blind 7. Auditory acuity-how well do you think the dog hears? (select only one) No apparent change in auditory acuity Some decrement in hearing-not responding to sounds to which the dog used to respond Extreme decrement in hearing-have to make sure the dog is paying attention or repeat signals or go get the dog when called Deaf-no response to sounds of any kind 8. Play interactions-if the dog plays with toys (other pets are addressed later), which situation best describes that play? (select only one) No change in play with toys Slightly decreased interest in toys, only Slightly decreased ability to play with toys, only Slightly decreased interest and ability to play with toys Extreme decreased interest in toys, only Extreme decreased ability to play with toys, only Extreme decreased interest and ability to play with toys 9. Interactions with humans-which situation best describes that interaction? (select only one) No change in interaction with people Recognizes people but slightly decreased frequency of interaction Recognizes people but greatly decreased frequency of interaction Withdrawal but recognizes people Does not recognize people 10. Interactions with other pets- which situation best describes that interaction? (select only one) No change in interaction with other pets Recognizes other pets but slightly decreased frequency of interaction Recognizes other pets but greatly decreased frequency of interaction Withdrawal but recognizes other pets Does not recognize other pets No other pets or animal companions in house or social environment 11. Changes in sleep/wake cycle (select only one) No changes in sleep patterns Sleeps more in day, only Some change-awakens at night and sleeps more in day Much change-profoundly erratic nocturnal pattern and irregular daytime pattern Sleeps virtually all day, awake occasionally at night Sleeps almost around the clock 12. Is there anything else you think we should know? ————————————————— ————————————————— —————————————————
