Happy Tails Dog Behavior & Training
Daina Beckman 607-698-9122
doghelp@hughes.net

INITIAL QUESTIONNAIRE
INSTRUCTIONS: Please fill this out as completely as possible. The boxes appear to be small, but as you type they will become bigger making enough room for as much as you want to type.

The information from this form will be used during your consultation to develop a diagnosis and a behavior modification plan. Please fill it out as completely as you can. All information will be held in strict confidence and will not be released to any third party without your written request.
Today’s Date:
GENERAL INFORMATION
Your name: Your vet’s name:
Your address: Your vet’s address:
Home phone: Your vet’s phone:
Work/Day phone:
Your e-mail:
Your dog’s name:
Your dog’s breed:
Your dog’s age:
Your dog’s date of birth:
Is your dog male or female?
Date of most recent Rabies vaccine: 1 year or 3 year?
Date of Distemper vaccine:
List Other vaccines and date they were given:
How long have you had your dog?
DOG’S BACKGROUND
1. Is your dog spayed or neutered?
2. If yes: What age?
3. If female, did your dog experience heat cycles before neutering?
4. Age of first heat, if applicable:
5. Were there any behavior changes after neutering?
If yes, please explain:
If no:
6. Do you plan to breed this dog?
7. Has this dog ever been bred?
8. If yes and female, was she a good mother?
9. If female, when was the last heat cycle? Was it normal?
DIET AND FEEDING
1. What is your dog fed? (include the brand of dog food)
2. If known, what is the percent fat and protein in the food: % protein % fat
3. How often do you feed your dog each day?
4. How much do you feed your dog (cups)?
5. How often is your dog fed treats each day?
6. Is your dog fed human food?
7. If yes, how often per day? What exactly is fed?
8. Who feeds the dog?
9. Where is the dog fed?
10. Where does the dog drink?
ADOPTION HISTORY
1. Why did you decide to get a dog? (i.e., companionship for you/companionship for another pet/other
2. Have you owned dogs before?
3. Why did you choose this breed? (i.e., no reason/size/ lifestyle/like this breed/other)
4. Where did you obtain this dog? (i.e., SPCA/rescue league/no-kill shelter/breeder/friend/pet store/stray/other)
5. Why did you choose this breeder?
6. Why did you choose this particular dog?
7. Was a temperament test performed before you obtained the dog? (yes, no, unsure)
If yes, at what age was it performed?
What was the result?
8. If known, describe your dog’s behavior as a puppy:
9. Has your dog had previous owners?
If yes, how many?
If yes, did previous owners report behavior problems?
Please explain:
At what age was the dog given up by the previous owners?
Why was the dog given up?
10. Do any dogs related to the patient have similar behavior problems? (yes, no, unknown)
MEDICAL HISTORY
Please bring a summary of your dog’s medical record to the consult. This can be obtained from your veterinarian. If you do not know the answers to the questions in this section, please consult your veterinarian.
1. Does your dog have any skin problems?
If yes, please explain:
2. Does your dog have any preexisting or current medical problem?
If yes, what is the problem?
3. Does your dog have allergies?
If yes, please list them:
4. Is your dog currently on any medication?
If yes, please list the medication, dosage, and reason for giving the medication:

Medication                      Dosage                       Reason

List any medications your dog stopped taking during the last year:
Medication Dosage When Stopped



5. Has your dog had bloodwork done within the last year?
If yes, were the results normal?
If no, what were the abnormal results?
6. Has your dog ever had a serious injury or an injury that was traumatic to him?
If Yes, how old was he?
Describe the injury and event
7. Does your dog seem to drink a lot?
If yes, explain:
8. Does your dog ever seem to be walking like he is drunk?
9. Does your dog walk or run in circles?
10. Does your dog seem to urinate more than normal?
11. Is there anything you would like to add about your dog’s medical history?
HOME ENVIRONMENT
1. Please complete the following (hours per day) for all people in your household. It is only necessary to list age for children. (For additional people, just hit “tab” after the last age entered and you will get another line.)
Name Hours away from home Hours with dog Child’s age




2. Please complete the following for each animal in your household (list them in the order that they were obtained). Indicate in the last column whether the relationship to the patient is neutral, aggressive, or friendly.
Name Species Breed Sex Age obtained Age now Relationship




3. Has your household changed (people/animals) since acquiring your dog?
If yes, please describe:
Has anyone moved in or out or has any one passed away?
4. Have you moved since acquiring your dog?
If yes, how many times?
If yes, describe how your dog adjusted to the move(s):
5. Do you live in a city, town, suburbs, or rural area?
6. What type of housing (i.e., apartment, ranch, split level, two or more stories, trailer, etc.)
7. Is your yard fenced in?
If yes, what type of fence? (i.e., invisible, chain link, stockade, other)
8. Where is your dog when alone in the house?
9. Where is your dog when you/family members are home?
10. What percent of the time does your dog spend outside?
If your dog spends time outside, please describe where the dog is relative to your house, driveway, and road.
Is your dog supervised when outside?
How does your dog signal to go outside?
11. Where does your dog sleep at night?
12. How does your dog behave when you leave the house? (no reaction, looks sad, barks, paces, other)
13. What is your routine when you leave your house? In particular, how long do you spend with your dog just before leaving?
14. What is your routine on returning home to your dog?
DAILY SCHEDULE
Please describe a typical 24 hour day in your dog’s life. Please note times when the dog eats, sleeps, exercises, etc.

EXERCISE
1. How do you exercise your dog? (i.e., not exercised/allowed to run free and unsupervised/allowed to run free but supervised/walked on leash/free within a fenced-in area/tied outside/other)
2. How often do you exercise your dog per day?
3. What is the average length of the exercise session?
4. How do you play with your dog? (fetch/tug of war/Frisbee/ agility/other)
5. How often do you play with your dog?
6. What toys does your dog have?
7. Does your dog “mother” objects or other animals?
8. What is your dog’s activity level in general? (Low, average, high, excessive)
9. Does your dog go to day care?
If yes describe the day care and any behavior problems noted by the day care.
10. Does a dog sitter or friend come in to check on your dog during the day?
If yes, who and how often, what times?
OBEDIENCE/DOG SHOWS
1. What basic obedience training has your dog had? (None/trained at home/puppy kindergarten/basic group lessons/advanced group lessons/private trainer/began lessons but didn’t finish)
2. Age when dog began obedience training?
3. Who took the dog to training?
4. Does your dog have any awards or titles
If yes, please list:
5. Please list any special training that your dog has had (agility/hunting/herding/protection/attack/other):
6. Which commands does the dog know? Give name of each person in the household and how the dog responds (A Always; U Usually; S Sometimes; N Never).
Examples: Mary-U; Jack-N
Sit
Stay
Lie Down
Come
Heel
Fetch
Drop it
Other

7. Does your dog know any tricks?
8. Have you shown your dog in a dog show?
If not, do you plan to?
HOUSE TRAINING
1. Is your dog house trained?
2. If yes, how old was the dog when it was house trained?
3. If yes, how was the dog house trained?
4. Does your dog ever eliminate in the house?
Urine or feces?
If yes, how often and under what circumstances?
Where does your dog urinate/defecate in the house?
When does your dog urinate/defecate in the house?
Does your dog urinate or defecate on items?
If yes, describe what your dog urinates/defecates on.
Does your dog urinate or defecate when family members are home?
If yes who is home?
Does your dog urinate/defecate in the house only when certain family members are away?
If yes explain.
If your dog is urinating in the house is it one large puddle or several small puddles?
REASONS FOR CONSULTING A BEHAVIOR COUNSELOR
1. Check all that apply:
Only curious.
I would like to change the problem, but the problem is not serious.
The problem is serious and I would like to change it, but if it remains unchanged, I will keep my dog.
The problem is very serious and I would like to change it, but if it remains unchanged, I will place my dog in a shelter/rescue league/another home.
The problem is very serious and I would like to change it, but if it remains unchanged, I will have my dog euthanized.
Other:
2. What are your goals in changing your dog’s behavior (that is, what do you expect to accomplish)?

BEHAVIOR
1. Does your dog jump on you or others without permission?
2. Does your dog sit on your feet while you are sitting or lie on you while you are prone?
3. Does your dog paw at you or others?
4. Does your dog lick you?
5. Does your dog mount people?
If yes, whom does he or she mount?
6. Does your dog mount objects or other animals?
If yes, please specify:
7. Does your dog ever bark at you?
If yes, please explain:
8. Does your dog bark at other times?
If yes, please explain:
9. Does your dog lean on you or others?
10. Does your dog run into you or others?
11. Does your dog chew on things?
Describe in detail.
12. What things does your dog chew on?
13. When does your dog chew on things? Describe in detail.
14. Are any family members at home when your dog is chewing on things?
Explain:
15. Are specific family members gone when your dog chews on things?
Explain:
16. Where are the items located when your dog finds them to chew on them?
17. Where does your dog chew on things he finds?
18. Where does your dog leave the things he has chewed on?
19. Does your dog lick himself?
If yes explain:
20. Does your dog bite his toe nails?
21. Explain your dogs barking habits:
22. Have neighbors complained about your dog barking?
23. Does your dog bark when you are gone?
If yes, is it continuous or intermittent?
24. Does your dog like to ride in the car?
25. Describe what your dog does in the car.
26. Have you left your dog alone in the car?
27. How did he behave when left alone in the car?
28. Has your dog ever chewed upholstery in the car?
29. Does your dog bark when riding in the car?
If yes, describe:
30. What is the main behavior problem or complaint?
31. Additional problems?
32. For the main problem, how often does it occur?
33. Are there any specific events/conditions that will trigger the problem behavior?
If you can identify the situation during which the main problem occurs, how often does it occur when the dog is presented with that situation (1 time in 10 = 10%; 5 times in 10 = 50%):
34. How old was your dog when you first noticed the main problem?
35. Describe how the problem developed over time:
36. When did it first become a serious concern?
37. Under what general circumstances does the dog misbehave?
38. If possible, describe how your dog acts before the problem behavior occurs and after the behavior occurs:
Before:
After:
39. Does your dog respond by name or seem aware of the surroundings during the problem behavior?
40. Can you interrupt your dog’s problem behavior?
41. How long does the behavior last?
42. What is the average time between recurrences of the behavior?
43. If you have other pets, how often does their presence or absence affect your dog when the problem behavior occurs? Please explain.
44. If known, what are the actions/responses of any people present before, during and after the problem behavior occurs?
45. Please describe several examples of the problem behavior in detail. If possible, note the time of day, location and presence/absence of other people and animals:
Most recent incident:
Second most recent incident:
Third most recent incident:
Other significant incidents:
46. Has the main problem changed in frequency (now happening more often, less often, etc)? Please explain:
47. Has the main problem changed in intensity? Please explain:
48. Has the main problem otherwise changed? Please explain:
49. What have you done so far to correct the problem? Check all that apply:
Nothing
Actively ignore the dog
Verbal reprimand
Strike with hand or newspaper
Isolate to crate
Isolate to room
Isolate outside
Startle with sound or water
Distract to another activity
Roll dog onto his/her back (alpha roll)
Scruff shake
Citronella collar
Shock collar
Prong collar
Choke collar
Other:

50. Please list the frequency of additional problems (times per day, week or month) and likelihood of occurrence
(if your dog is in the situation ten times, how often will the behavior occur):
Additional Problem Frequency Occurrence