Vet-to-Vet Canine Behavior Consultation Form "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.General Information & Medical HistoryClinic name*Veterinarian’s name*Referring veterinarian type* Patient’s primary care vet Specialist Other Specialty (if specialist)If other, please describeHow did you hear about us?Date of pet’s last veterinary visit* MM slash DD slash YYYY Has the dog had baseline blood work (CBC, chemistry) performed within the past year?* Yes No Date of last blood work MM slash DD slash YYYY Any abnormal resultsCurrent medications, supplements, or other treatments*Name & FormulationDose (in mg)Frequency (e.g. every 24 hours, as needed) Add RemovePlease list name & formulation, dose (in mg), and frequency (e.g. every 24 hours, as needed).Has the dog previously been prescribed medications, supplements, or pheromones for behavior that are not listed above?* Yes No If yes, please list the name, date started, date discontinued, dose, and effectsAny chronic medical conditions?* Yes No Chronic medical conditions – explain*Any current or history of pain (limping, difficulty getting up or lying down, resistance using stairs, slowing down on walks)?* Yes No Pain history – explain*Any appetite concerns?* No Excessive Good/Average Poor Appetite concerns – explain*Basic Pet InformationDog’s name*Signalment*Include species, breed, sex, reproductive status, and age.Weight (indicate pounds or kilograms)*Relevant history prior to acquisition, if knownDoes the dog have signs of generalized anxiety disorder?For example: easily startles with changes or subtle noises, difficulty settling within the home.Current Behavior ProblemsDescribe the main behavioral concerns that prompted the consultation*Provide details surrounding the problem (location, people or animals involved, frequency, etc.)*How old was the dog when it started?*Household OccupantsHousehold occupantsNameRelevant information about care/relationship Add RemoveList all household members and relevant information about their care/relationship with the dog.Household Pets (aside from dog presenting for evaluation)Household petsNameSpecies Add RemoveList all other pets in the household.Training and ObedienceHas the client worked with a trainer? Group classes Private in-home Virtual No Trainer informationInclude trainer name, business, and any other relevant information.Training aides currently used (e.g. prong collars, electric collars, penny can, head halter, front-clip harness)Training aides used previouslyDaily ActivitiesWhat daily exercise and enrichment does the dog receive?Does the dog show signs of stress while the clients are gone and if so, which ones? No Urination Defecation Hypersalivation Destructive behavior Vocalization Other If there is suspected separation-related problems, please provide more information (what has been attempted, departure protocols, etc.)Future ConsiderationsWhat are the client’s goals for treatment?*Are they considering rehoming or behavioral euthanasia for their dog?*Additional comments or information that did not fit in any other section
