Dog behaviour questionaire Survey

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* 1. Owner details

Name

Address

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 2. Patient details

Name

Breed

DOB

Sex

Desexed

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* 3. Referring veterinarian information

Clinic name

Clinic phone number

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* 4. Trainer information

Trainer's name

Trainer's phone number

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* 5. How did you find us?

Referred by vet

referred by trainer

web site

word of mouth

saw the clinic

Other (please specify)

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* 6. Please list the problems you are concerned about (we will deal with each of these in more detail later)

Problem one

Problem two

Problem three

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* 7. Regarding problem one

Problem

How often does it occur?

When did it start?

When and where does it occur?

Is the problem getting worse?

Any other comments about the problem?

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* 8. Regarding problem one how serious is the problem?

not very serious

somewhat serious

serious

very serious

extreme

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* 9. Regarding problem two

Problem

How often does it occur?

When did it start?

When and where does it occur?

Is the problem getting worse?

Any other comments about the problem?

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* 10. Regarding problem two how serious is the problem?

not very serious

somewhat serious

serious

very serious

extreme

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* 11. Regarding problem three

Problem

How often does it occur?

When did it start?

When and where does it occur?

Is the problem getting worse?

Any other comments about the problem?

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* 12. Regarding problem three how serious is the problem?

not very serious

somewhat serious

serious

very serious

extreme

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* 13. People, please list the people living in your house starting with yourself

Name

Gender

Age

Relationship to yourself

Occupation

Name

Gender

Age

Relationship to yourself

Occupation

Name

Gender

Age

Relationship to yourself

Occupation

Name

Gender

Age

Relationship to yourself

Occupation

Name

Gender

Age

Relationship to yourself

Occupation

Name

Gender

Age

Relationship to yourself

Occupation

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* 14. Please list any other pets currently living in the household

Name

Species

Age

Sex

Desexed?

Name

Species

Age

Sex

Desexed?

Name

Species

Age

Sex

Desexed?

Name

Species

Age

Sex

Desexed?

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* 15. All these questions refer to the patient coming in for the consultation

What age did you acquire your pet?

From where?

If a rescue do you know why they were surrendered?

Did they go to puppy pre school?

If so where?

Was your puppy well socialised for the first few months of life?

Does you dog like meeting new dogs on lead?

Does your dog like meeting new dogs off lead?

Has your dog ever been involved in a fight?

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* 16. Does your dog like people? Tick all that apply

Family

Strangers at home

Strangers on the street

Children

Babies

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* 17. Has your dog ever bitten anyone?

Yes

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* 18. If yes please give details

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* 19. Has your dog's personality changed over time? If so how?

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* 20. What rewards do you use for your dog (food,praise, ball etc.?)

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* 21. What is your dog's favourite pastime?

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* 22. Where is your pet when you are not at home?

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* 23. Where does your dog sleep at night?

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* 24. Is your dog crate trained

Yes

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* 25. What do you feed your dog?

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* 26. Do you ever feed bones?

Yes

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* 27. How does you dog react to

Loud noises

The car

New places

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* 28. In one or two words describe how you view your dog's personality

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* 29. Does you dog chase its tail excessively?

Yes

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* 30. Pace excessively?

Yes

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* 31. Try to escape when you aren't at home?

Yes

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* 32. Bark when you aren't at home?

Yes

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* 33. Show destructive behaviour when you aren't at home?

Yes

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* 34. Eat when you aren't at home?

Yes

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* 35. Toilet inside?

Yes

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* 36. Has your dog ever been the subject of a court order?

Yes

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* 37. Been issued a dangerous dog notification?

Yes

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* 38. What sort of collar or harness do you use to walk your dog?

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* 39. Have you attended dog training? If so briefly describe the training & how it went.

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* 40. Have you ever used deterrent devices such as shock or citronella collars or remote devices including spray bottles?

Yes

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* 41. If you answered 'yes' to the previous question please describe what you have used

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* 42. Do you use food toys/puzzles or other enrichment toys? If so which ones?

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* 43. Patient medical history, (please give details) does your dog have

Pre-existing medical conditions

Chronic pain

Current medication

Blood test in last 12 months

Previous behavioural medications

Any non prescription medications including natural remedies or food additives

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* 44. Anything else you would like to add about your pets behaviour?

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* 45. Can you please bring a rough sketch of the floor plan of your house and yard to the appointment to help devise a management strategy specific to your household?

Yes

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* 46. Which of these statement applies to you?

I am only here out of curiosity: the problem is not serious

I would like to change the problem but it is not serious

The problem is serious: I would like to change it but if it remains unchanged that is alright

The problem is very serious: I would like to change it but if it remains unchanged I will keep my dog

The problem is very serious: if it remains unchanged I will euthanase or rehome my dog

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* 47. During our consultation we will be discussing tolerance of risk. Do you understand that in treating behavioural problems there is always some element of risk? While treatment will address that risk it can never completely eliminate it.

Yes