Owner's Name *

First

Last

Email *

Dog's Name *

Chief Complaint: In one or two sentences describe the primary reason you’re bringing your pet for a behavior consult. *

General History

Length of Ownership: Please describe how and where you acquired your pet. Make sure you address the following items

How long have you had your pet and when and where did you acquire him/her?
If you acquired him/her from an animal shelter or rescue organization do you know why she was surrendered to the organization?
Why did you get your pet?

Comments on ownership *

Reproductive History: Please describe your pet’s reproductive status. Make sure you address the following questions. Is your pet neutered?

If so, at what age and what was your reason for neutering.
Did you notice any behavior changes at the time of neuter?
If not neutered do you plan on showing or competing with your pet and then breeding?
Has your pet ever been bred?

Comments on reproductive history *

Diet: Please describe your pets eating habits

What type and brand of food does your pet regularly eat?
How often and how much do you feed and how much of it does he/she eat?
Does he/she eat it all right away?
Where is he/she fed and by whom?
Does he/she get table scraps, treats, or supplements more than 2x a week? If so, how often and what?

Comments on diet *

Basic Medical Status

When was your pet’s last veterinary health check? *

Are vaccines current? If so, when were they given? *

Is your pet on flea preventive medication? Which one? *

History of Medical Problems: Please describe your pet’s health and medical status. Make sure you address the following questions.

Does your pet have any known medical problems or past surgeries?
Is he currently being treated for medical problems?
Has your veterinary performed a medical workup for the behavioral problem? (please describe)

Comments on medical problems *

Please list all the animals in the household *

(Name, breed, sex, age obtained, current age, problems with the patient)

Please list the people, including yourself, currently living in the household *

(Name, sex, age range, relationship, occupation)

Exercise

Describe the type and amount of exercise your pet gets on a daily basis. Please address the following questions.

How frequently and how long are his walks?
Does he play fetch or with toys on walks or at home? (how long?)
Describe any other exercise.

Comments on exercise *

Daily Routine

Where does your dog stay during the day when you’re home? *

Where does he stay at night? (where does he sleep) *

Where does he stay when guests visit? *

What percentage of time does he spend indoors vs outdoors? *

Does he/she roam the neighborhood freely? *

Training/Socialization: Now describe your dog’s socialization, training, and overall obedience.

Has your dog has formal training or socialization classes? If so, when, where, who took him, and how did he/she do?
What will he/she do on command at home? What will he do when distracted, such as when visitors come over or when there’s some outside distraction.
Anything else we should know about his/her training and socialization?

Comments on training/socialization *

Specific Aggression History Questions

Targets of Aggression: Who are the targets of your dog’s aggression? *

BEHAVIOR AT HOME

Check the following behaviors during each activity and who they exhibit it towards. Family refers to anyone the dog lives with.

Family member walks by dog while dog’s eating *

Someone takes filled food bowl away *

Who do they exhibit the above behavior towards?

Family
Stranger

Take empty food bowl away *

Who do they exhibit the above behavior towards?

Family
Stranger

Take water dish away *

Who do they exhibit the above behavior towards?

Family
Stranger

Take bone away *

Who do they exhibit the above behavior towards?

Family
Stranger

Take toy away *

Who do they exhibit the above behavior towards?

Family
Stranger

Take treat away *

Who do they exhibit the above behavior towards?

Family
Stranger

Take stolen object away *

Who do they exhibit the above behavior towards?

Family
Stranger

Family member tries to get dog off bed, couch, chair, etc. *

Family member walks by dog while he’s resting or sleeping *

Someone stares at or looks into his eyes *

Who do they exhibit the above behavior towards?

Family
Stranger

Someone stands or leans over dog *

Who do they exhibit the above behavior towards?

Family
Stranger

Family member bumps into dog or try to push him out of the way *

Someone pets dog *

Who do they exhibit the above behavior towards?

Family
Stranger

Family member grooms dog *

Family member bathes dog *

Family member touches dog’s toe nails or handles feet *

Someone tries to make dog sit or lie down when he doesn’t want to *

Who do they exhibit the above behavior towards?

Family
Stranger

Family member tries to restrain him for other procedures he want to avoid *

Family member reprimands him *

Family member reaches over his head or towards him quickly *

Family member puts leash on or take it off (or grab collar) *

Family member correct by jerking on choke chain or collar *

Does he stand tensely over people? *

Who do they exhibit the above behavior towards?

Family
Stranger

Behavior at the Vet Hospital, Groomers, or With Unfamiliar People

Hospital staff or groomer leans over your dog to pet him or examine him *

Someone tries to lift dog *

Someone grooms the dog *

Dog is restrained for a non-painful procedure such as vaccinations, X-rays, nail trim *

Veterinarian approaches dog *

Someone approaches dog in cage or kennel *

Person approaches on the street *

Chase Behavior

Dog spots a squirrel, wildlife, or cat *

Dog spots a small dog *

Dog spots a large dog *

Dog hears or sees an infant crying *

Dog sees children under 5 years running or yelling *

Dog sees older children or adolescent running *

Dog sees jogger running *

Spots bicycler, skateboarder, or rollerblader *

Spots moving vehicles such as cars and buses *

Spots UPS truck or postman away from his property *

Territorial Behavior

Stranger approaches the car *

Stranger rings the doorbell *

Non-family member enters the household with owner’s permission *

Postman or delivery person approaches the property *

Someone raises his voice towards a family member *

Someone hugs owner in the presence of the dog *

Someone approaches owner while owner has the dog on leash (but not when dog is off leash) *

Bite or Snap History

Level One - Snap and miss
Level Two - Single bite with enough pressure to bruise or scrape
Level Three - Single bite that leaves punctures or tears from the canine teeth
Level Four - Single bite where the dog holds on and shakes or Multiple bites where the dog releases and grabs again
Level Five - Level four bite plus mutilation (body parts missing)
Level Six - Death

Please list the number of bites and level of bite below.

Number of total bites that broke skin (level 3 and above)? *

Number of total bites with enough pressure to bruise or scrape the skin? (level 2 and above) *

How many bites were reported and to which local authorities were they reported? *

Was legal action taken against the owner as a result of the bite(s)? *

Are the aggressive incidents more common with certain handlers? If so, whom? Explain. *

Are the aggressive incidents directed towards certain types of people? Explain *

How often does the problem behavior(s) occur? Daily, weekly, every time you encounter a specific situation? Explain *

Can you predict when they will occur either based on your dog’s body language or based on the situation? *

Are you or your family members afraid or uncomfortable around your dog? (on a regular basis). Do you fear for you or your family’s safety? Explain *

What’s your ideal treatment goal? What will you be satisfied with? *

What will you do if you can’t meet your treatment goals? Rehome? Euthanasia? Avoid the aggressive situations? *

History and Progression of Bite or Other Aggressive Incidents

Please list all of the bite incidences in chronologic order in order to provide a clear picture of the progression of the signs. *

Describe the situation in detail and provide date/relative date of incident

Signature *

Canine Aggression Form