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GreenTree Animal Hospital

Separation Anxiety Form

Thank you for choosing us! Please fill out the following form before your scheduled appointment.

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Separation Anxiety Form

Please note: All * fields are required. If you have any questions, please call us at 847-680-6543.

Name *

First

Last

Pet's Name *

Email *

Phone *

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

When did you FIRST notice it? *

When did you first realize it was a problem? *

Describe a typical episode or event. *

Has the problem gotten worse? If so, over what time period? *

Goals: What is your ultimate goal? What will you be satisfied with? What will you do if you cannot reach these goals? (Find a new home? Return to breeder? Euthanize?) *

How long have you had your pet and when and where did your acquire him/her? *

If you acquired him/her from and animal shelter or rescue organization do you know why she was surrendered to the organization? *

Why did you get your pet? *

Is your pet neutered/spayed? *

Yes
No

If so, at what age and what was your reason for neutering/spaying? *

If not neutered/spayed, do you plan on showing or competing with your pet and then breeding? *

Has your pet ever been bred? *

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? *

Yes
No

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? *

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

Are vaccines current? (DHLPP, RABIES, FVRCP (cats))? *

Is your pet currently on any medications such as for flea prevention or heartworm prevention. If on medications for health reasons, please describe why. *

Does your pet have any known medical problems or past surgeries? *

Yes
No

Is he currently being treated for medical problems? *

Yes
No

Has your veterinary performed a medical work-up for the behavioral problem? (please describe) *

Please list all animals in the household *

(Name, breed, sex, age obtained, current age, any problems)

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

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

How frequently and how long are your dog's walks? *

Does he play fetch or with toys on walks or at home? (how long?) *

Describe any other exercise. *

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

Where does he/she stay at night? (where do they sleep) *

Where does he/she stay when guests visit? *

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

Does he/she roam the neighborhood freely? *

Yes
No

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? *

Destruction: Does the dog destroy or chew inappropriate objects (carpet, wall, door, fence, furniture) mainly when separated from a primary attachment figure? *

Inappropriate Urination/Defecation: Does the dog urinate or defecate in inappropriate locations (e.g. in the house or in its crate) when separated from a primary attachment figure? *

Vocalization: Does the dog bark or whine excessively when separated from a primary attachment figure? *

Dogs behavior when owner’s at home: Does the dog follow the primary attachment figure around the house constantly? (even into the bathroom) *

Dog’s behavior before the owner leaves: Does the dog become distressed when the primary attachment figures looks like he or she is going to leave the house? *

Dog’s behavior upon owner’s return: Does the dog display destructive behavior only when separated from a primary attachment figure? *

Treats & Toys: Will the dog eat treats or a meal or play with toys when separated from the primary attachment figure? *

Please note whether these objects are gates, windows, or doors that lead out of the yard or house, and approximate cost of damage. *

Include whether your dog has injured themselves in the process of chewing or destroying objects. *

Have you kept him/her in a crate or in wire kennel when gone? If so, has he damaged it? *

Describe the inappropriate urination and defections. (Which does he do and when does he do them?) *

How long after you leave do they vocalize? *

How long does it last? What does it sound like? (pitch, rate). *

Are they barking at specific stimuli such as people going by or cars passing? *

When do they stop? What makes them stop? *

Do your neighbors complain? *

Whom do they follow the most? Do they follow one more people closely? *

Do they always need to be in the same room as their favorite person? Or can they be in a separate room with the door open or closed? *

When they're in a room with someone, do they want to be right next to people or in physical contact with people at all times or within 1 foot or can they sit or lie down several feet away? *

What do they do if separated in another room (door closed?) *

What do they do if they're in a kennel or crate? With you in the room or out of the room? *

What do you do when they whine or bark while separated from you in the house? *

How long before you leave the house do they start showing signs of anxiety? *

What signs do they show? *

Name all of the departure cues that trigger this anxiety. *

(i.e. picking up your car keys, grabbing your coat, putting a certain pair of shoes on etc)

What do they do immediately after you leave? *

(i.e. you peer back into the house when she thinks you’re gone)

Where do you put them when you leave? *

What’s their response to your above-listed attempts to make them feel better when you leave? *

Do you have other pets that stay home with them? *

How do you greet them when they comes home? *

(i.e. do you praise her or play with her and pet her or is it a tempered greeting? *

If off leash, do they stick right next to you or wander away? If they wander away, how far? Do they frequently look back to see where you are? If you call them, will they come immediately the first time? *

Signature *

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Address

800 E. Park Ave (Rt. 176)
Libertyville, IL, 60048

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Hours of Operation

Mon, Tues, Thurs, Fri: 8:00 am - 6:00 pm

Wed: 8:00 am - 2:00 pm ; 3:00 pm - 7:00 pm

Sat: 8:00 am - 12:00 pm

Sun: Closed

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Hours of Operation

Mon, Tues, Thurs, Fri:
8:00 am - 6:00 pm

Wed:
8:00 am - 2:00 pm
3:00 pm - 7:00 pm

Sat:
8:00 am - 12:00 pm

Sun:
Closed

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