Dog History Behavior Form

"*" indicates required fields

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Client Information

Due to time constraints, during the appointment we will focus on one or two behavior problems. We can make note of other unwanted behaviors to address at a later date, but the initial consultation will be geared toward assessing, diagnosing, and explaining your options to improve your cats' main or most serious behavior problem. Your information is saved on our server as you enter it.

Today's Date*

MM slash DD slash YYYY

Name*

First Last

Preferred Pronouns*

She/her/hers

He/him/his

They/them

Other

Email*

Phone*

Client Birthday*

MM slash DD slash YYYY

List each person living in the household.*

Name

Age

Preferred Pronouns

Relationship to you

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dog Information

Dog's Name*

Dog's Breed*

Dog Color*

Dog's Age*

Note months and years if applicable.

Dog's Sex*

Female

Male

Is your dog spayed or neutered?*

Yes

Dog's Weight*

in pounds

Name of Regular Veterinarian*

Email of Regular Veterinary Clinic

Phone of Regular Veterinary Clinic

How were you referred to us?*

Household Information

What type of residence do you have?*

Townhome

Condo

Apartment

Single-family home

What type of neighborhood do you live in?*

Urban

Suburban

Rural

Do you have a yard?*

Yes

If your yard has a fence, please check all that apply*

Less than 6 feet tall

More than 6 feet tall

Wood

Chain link

Brick

Pets living in the household. (Comment on the relationship between the cat with the behavioral problem and your other pets: e.g. "get along" or "neutral" or "conflict")

Name

Species

Breed

Age

Sex

Spayed/neutered?

Relationship with patient? ONLY use "get along," neutral," or "conflict"

Medical History

Medication: Indicate any medication your dog currently receives (e.g., thyroid medication, fluoxetine, trazodone, etc.)

Name of Medication

Dose (mg) or amount

How often

When was it started

Medical problems

Problem

Dates, if known

Ongoing? Yes/no

How often does your pet perform the following? (Answer with: never, daily, weekly, monthly, or several times a year)*

Diarrhea/loose stool

Vomiting

Decreased appetite

Constipation

Excessive licking/grooming

Eating non-food items

General

What is your primary goal for this appointment?*

Pet Acquisition Background

How old was your dog when you first acquired them?*

Where did you obtain your dog?*

Behavior problems of parents or littermates, if known

Primary Problem Statement

In 2-3 sentences or bullet points, describe the main behavior problem that you would like us to help with.*

How old was your dog when the problem started?*

Frequency

Is the frequency of the main problem increasing, decreasing, or staying the same?*

Do the behavior problems occur at particular times of the day or night? Please explain*

How have you addressed the problem so far?

Avoided exposure*

Yes

Treats*

Yes

Hired professional help*

Yes

Clicker training*

Yes

Increased play*

Yes

Increased exercise*

Yes

Time out*

Yes

Verbal scolding*

Yes

Water bottle/spraying*

Yes

Sound/noisemaker*

Yes

Spanking/pop on the nose*

Yes

Leash corrections*

Yes

Vibration/electric collar*

Yes

Rollover*

Yes

Prong or choke collar*

Yes

If you are currently working with a trainer, please provide their name and contact information here

Please list all trainers you have worked with, including board and train

General Behavior Towards Others

Indicate your dog's response to the following triggers. Check all that have ever applied.

Check which triggers cause your pet to show aggression (any of the following behaviors: growling, barking, lunging, snapping, and/or biting) towards:*

Family members living in the home

Strangers

Visitors

Children

Other dogs outside your home

Approached by people while eating or having a special treat or toy

Approached by other pets while eating or having a special treat or toy

Moved/pushed off furniture (couch, bed)

At the veterinary clinic

Cyclists/motorbikes

Cars/trucks

Check which triggers cause your pet to show fear/anxiety (any of the following behaviors: cowering, retreating or hiding, excess drooling, excess panting or pacing, whining, crying) towards/during:*

Family members living in the home

Strangers

Visitors

Children

Other dogs outside your home

Approached by people while eating or having a special treat or toy

Approached by other pets while eating or having a special treat or toy

Moved/pushed off furniture (bed, couch)

At the veterinary clinic

Cyclists/motorbikes

Cars/trucks

Novel objects/places

Car rides

Noises

Fireworks

If your dog has bitten a person, please describe.

Who

Trigger

What part of body

Did it break skin

If your dog has bitten another dog, please describe:

Who

Trigger

What part of body

Did it break skin

Has your dog been reported to animal control?*

Yes

Did your dog receive a vicious and dangerous dog citation?*

Yes

Sleeping Habits

Does your dog sleep through the night?*

Yes

Leashed Exercise

How often does your dog get regular leash walks?*

Who takes your dog for leashed walks?*

What equipment is used to walk your dog?*

Front buckle collar

Front buckle body harness

Head collar (gentle leader)

Electronic (shock/vibration) collar

Training or choke collar

Retractable leash

Prong collar

Average leash (4-6 feet)

If other, please describe

Living Spaces/Being Left Alone

When is your dog left alone? (e.g., 8 am – 5 pm Monday through Friday)*

What is your dog's reaction to being left alone?*

Calm

Vocalizes

Agitated

Escapes

Urinates or defecates

Destructive

Pants

Drools

Where does your dog spend most of the time when people are not home?*

Loose in the house

Confined to a part of the house

Inside a crate or a pen

Loose in the yard

Outside in a kennel

Have you ever considered euthanizing your dog because of the behavior problem?*

Yes

Any comments?

Have you ever considered rehoming your dog because of the behavior problem?*

Yes

Any comments?

Client Service Agreement

All clients are informed of our policies via email. This information can also be requested by other means (mailing address, fax) if requested by the client. By signing this document and/or scheduling an appointment with the SF SPCA Behavior Specialty Service, clients are agreeing to comply with the service’s policies, protocols, and expectations. Results and progress may vary depending on various factors and are not guaranteed. Any photo or videos taken during the consultation may be used as part of your pet’s medical record.

We often utilize pictures and videos taken during the consultation or submitted to the SF SPCA Behavior Service in educational seminars and programs. Actual names of clients and patients are not used. Clients will not be entitled to inspect or approve the use of these pictures and videos, or receive notice of their use or publication, or receive any payment. Do you authorize the use of your pet’s pictures and videos?*

Yes

Do you authorize sharing medical records with veterinarians providing care to your pet?*

Yes

Do you authorize sharing medical records with trainers approved by our service that request patient information?*

Yes

Terms and Conditions*

I understand and agree.

I have read the policies and procedures put forth in the San Francisco SPCA Behavior Service Agreement, and understand them fully. I agree to adhere to these policies as a client of the San Francisco SPCA Veterinary Hospital. By signing this document, I am confirming that I am at least 18 years of age, I am the legal owner of my pet(s) that are being evaluated, and that I agree to comply with the policies and terms explained in this document. I consent to and authorize the SF SPCA Behavior Specialty Service to treat my pet(s) and I assume financial responsibility for all related fees.

Signature*

I hereby confirm that I have read and agree to the cancellation policy, email policy, and refill policies for the SF SPCA Behavior Specialty Service. I understand that I may be charged a cancellation/reschedule fee if I fail to abide by the above cancellation policy. I understand that I may be charged an emergency refill fee if I request a refill be addressed within 48 hours.*

Signature*

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