Canine Initial Behavior Consultation History Please complete the form below prior to your appointment. If you have any questions please email us at info@metro-vet.com. "*" indicates required fields General InformationName* First Last Date of Appointment* MM slash DD slash YYYY Who referred you?*Basic Pet InformationDog's Name*Current Age (indicate months or years)*Breed*Sex*MaleFemaleSpay or Neutered?* Yes No Date When Acquired* MM slash DD slash YYYY Source Breeder Shelter/Rescue Stray Other Did you meet your dog's parents?* Neither Mother only Father only Both Mother and Father History Prior to Acquisition (if known)Household InformationHousehold Members (including you)*NameAgeRelationship to youOccupationRelationship with pet (e.g., follows, trains, no interaction, etc.) Add RemoveIs anyone in the household pregnant or planning to adopt or foster a child in the near future? (This is asked for safety reasons. You are not obligated to answer.) Yes No Please provide a due date if applicable or any relevant informationHave you had dogs as an adult before? Yes No Household Pets (aside from dog presenting for evaluation)NameSpeciesAge, breed, sex, neuter statusInteractions with patient Add RemoveWhat type of area do you live in?*SuburbanUrbanRuralVillageOtherOther type of area:*What type of home do you reside in?*Apartment/CondoTownhouseSingle family houseOtherOther home type*Do you have a yard?* Yes No Do you have a fence?* Yes No What type?*Are you planning on moving within the next few months?* Yes No When and where?*Have there been any changes in your household since acquiring your dog (e.g. new job, move)?* Yes No Explain:*Aggression (if applicable)Only fill out information about triggers that apply to your dog; otherwise leave the field blank.For any trigger applicable to your dog, please describe specific incidents of aggression including:your pet’s age when it was first observed and at the time of incident(s)targets of the aggressionlocationhow you respondedfrequency of incidentsbody language (growling, barking, lunging, biting)any other relevant informationPeople living in the homeOther pets in the homeGuestsUnfamiliar people passing or approaching the home/yardStimuli (dogs, strangers, cars, etc.) on walksUnfamiliar dogs when off leashVeterinary clinicOther triggers of aggression not listed aboveBite History (if applicable)Has your dog made contact with an individual during the aggression? Yes No What type of injury? Scratch Bruise Puncture(s) Tear How many times has your dog bitten a person?How many times has your dog bitten a dog/other animal?How many times did a bite break skin with a person?How many times did a bite break skin with an animal?If your dog has a bite history, was any incident reported to Animal Control or other authorities? Yes No To whom?Is there any legal action pending because of this pet? Yes No Which incident(s)?*If not already described, please explain the bite incidents.Anxiety ScreenWhat is your dog’s response to changes in the environment or subtle, sudden noises?*Does your dog have any difficulty settling within the home?*Does your dog do any of the following more than you would expect? Lip licks or yawn Lick or chew their body Lick objects Lick people Does your dog display any reaction to noises such as thunderstorms, fireworks, or other loud noises?* Yes No Explain:*Does your dog do any of the following? Chase his/her tail Chase lights/shadows Snap at the air Other fears or anxieties not already describe:Describe your dog’s behavior at the veterinary clinic, if not already described:Does your dog show signs of stress while you are gone and if so, which ones?* No Urination Defecation Hypersalivation Destructive behavior Vocalization Other Other signs:*On average, how long is your pet home alone?*How do you prepare to leave your dog home alone?*Other Behavior ConcernsDescribe any other behaviors you find concerning that you have not yet mentioned.Daily ActivitiesIs your dog walked daily?* Yes No How often and for how long?*What other type of exercise does your dog receive? Fetch Run Agility Other Other types of exercise:*Is your dog playful?* Yes No Explain:*What kinds of toys does he/she like?*Is your dog ever confined?* Yes No During what situations is your dog confined?*With which method is your dog confined?*What is their response?*If crated, what type of crate?Where is the crate located? (if applicable)How do you get your dog inside? (if applicable)What does your dog have access to inside? (if applicable)Does your dog choose to spend time inside of it? (if applicable)Training and ObedienceHas your dog ever attended group training classes?* Yes No Companies/Trainers:Age of Dog (at the time):Have you ever hired a private trainer?* Yes No Companies/Trainers:Age of Dog (at the time):What cues does your dog perform regularly and reliably? Sit Down Come Place Look Touch Other How do you correct your dog when he/she misbehaves?*What types of training aides do you currently use?*What types of training aides have you previously used?*Medical HistoryPrimary Care Veterinarian Clinic*Veterinarian's Name*Date of Last Veterinary Visit MM slash DD slash YYYY Estimated Weight (indicate pounds or kilograms)*Has your dog had baseline blood work (CBC, chemistry) performed within the past year?* Yes No Date of last blood work* MM slash DD slash YYYY Please list your pet’s current medications, supplements, or other treatments belowName of heartworm preventativeName of flea/tick preventativeMedicationsNameDose (in mg)Frequency (e.g., once daily, as needed) Add RemoveHas your dog previously been prescribed medications, supplements, or pheromones for his/her behavior that are not listed above?* Yes No Please list the name, date started, date discontinued, dose, and effects.*Any chronic medical conditions?* Yes No Explain:*Any current or history of pain (limping, difficulty getting up or lying down, resistance using stairs, slowing down on walks)?* Yes No Explain:*Have you noticed your pet exhibiting any of the following in the last 3 months? Itching Vomiting Diarrhea Other What else?*Does your pet have a history of seizures?* Yes No Current Diet Brand*Amount and Frequency*How would you describe your dog's appetite?* Excessive Good/Average Poor Explain:Does your dog have any confirmed or suspected food allergies or sensitivities?* Yes No Note: We will offer treats during the appointment based on this answer.Explain:Future ConsiderationsWhat are your goals for treatment?*Have you considered rehoming or behavioral euthanasia for your dog?*Please tell us about your favorite qualities and interactions that you have with your dog!*
