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Dog History Behavior Form

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Step 1 of 7

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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.
MM slash DD slash YYYY
Name*
Preferred Pronouns*

MM slash DD slash YYYY
List each person living in the household.*
Name
Age
Preferred Pronouns
Relationship to you
 
Address*

Dog Information

Note months and years if applicable.
Dog's Sex*
Is your dog spayed or neutered?*
in pounds

Household Information

What type of residence do you have?*
What type of neighborhood do you live in?*
Do you have a yard?*
If your yard has a fence, please check all that apply*
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

Pet Acquisition Background

Primary Problem Statement

Frequency

How have you addressed the problem so far?

Avoided exposure*
Treats*
Hired professional help*
Clicker training*
Increased play*
Increased exercise*
Time out*
Verbal scolding*
Water bottle/spraying*
Sound/noisemaker*
Spanking/pop on the nose*
Leash corrections*
Vibration/electric collar*
Rollover*
Prong or choke collar*

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

Sleeping Habits

Does your dog sleep through the night?*

Leashed Exercise

What equipment is used to walk your dog?*

Living Spaces/Being Left Alone

What is your dog's reaction to being left alone?*
Where does your dog spend most of the time when people are not home?*
Have you ever considered euthanizing your dog because of the behavior problem?*
Have you ever considered rehoming your dog because of the behavior problem?*

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?*
Do you authorize sharing medical records with veterinarians providing care to your pet?*
Do you authorize sharing medical records with trainers approved by our service that request patient information?*
Terms and Conditions*
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.
*

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San Francisco Society for the Prevention of Cruelty to Animals is a 501 (c)(3) non profit organization. EIN: 94-0836580

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