The Behavior Clinic

CLIENT FORM Chicagoland Veterinary Behavior Consultants

John J. Ciribassi DVM, Terri Klimek Trainer Pat Rattray Administrative Assistant and Trainer Laura Monaco-Torelli, CPDT-KA, KPACTP Canine Case History Form

1042 Mountain Glen Way - Carol Stream, IL 60188 630-231-1544 [email protected] 630-554-0214 (fax) (Form courtesy of Purdue University College of Veterinary Medicine)

Please complete the following form and return it, along with any other forms emailed to you, to the flowing addresses: [email protected] and [email protected]

Use the Tab key to move between fields and enter information

NAME: E-MAIL FAX ( ) - ADDRESS: CITY ST ZIP PHONE: Home ( ) - Business ( ) - Clinic Name: Referring Veterinarian: Clinic Address: City: ST Zip Phone: ( ) - Fax ( ) - Referred By (if other than veterinarian)

Household: # adults (> 18 yr.): # children: ages: # dogs (including patient): List each family member living in the home (include sex and age):

Who is the primary caretaker of the dog:

Name Breed Sex Age (yrs) Rank PATIENT

Describe how pets get along:

Patient Information:

Weight: lbs. Body condition: Thin

Age neutered: yrs months Unknown

Current medical problem: Current medication: (include dose information, if known)

Origin: Own breeding Pet shop Other Breeder Humane society Don’t know Private Home Stray

Age obtained: (yrs) (months)

If obtained as a puppy, how was the puppy raised: In house Puppy mill N/A In kennel/garage Other Loose outside Don’t know

If obtained as a puppy, how did you select that particular puppy from a litter: Breeder selected Most timid Looks No choice Biggest Other Most outgoing Smallest N/A

If previously owned, for what primary purpose was the dog kept? Adult’s pet Watch/guard dog Research/teaching Family pet Farm/outside dog Other Children’s pet Obedience Don’t know Show dog Service/working dog N/A Breeding Hunting dog

Behavior of Parents or Littermates (if known): Primary purpose for which dog was obtained: Adult’s pet Breeding Service/working dog Family pet Watch/guard dog Hunting dog Children’s pet Farm/outside dog Other Show dog Obedience

Average # hours dog is left alone per WEEKDAY: (time spent without people) Schedule on weekdays Is consistent Varies

Describe your dog’s behavior when left alone at home:

What is the dog’s reaction at homecomings?

Is the dog ever alone outdoors? Yes How often? How long? (average) Where is the dog left when outdoors? How does your dog react to being left alone outdoors?

Where is the dog when left alone: Cage Garage Bedroom Confined in a room Outside kennel Other Loose in living area Outside tied N/A Basement Loose in yard

Where is the dog at night: Cage Basement On person’s bed Confined in a room Garage Outside kennel Loose in living area Bedroom Loose in yard Outside tied Other

Where is the dog placed when guests visit (or are there no restrictions)?

Exercise (walks): Never Several x/wk 1x/day 2x/day 3x/day >3x/day

Exercise schedule: Is consistent Varies during week

Average time of walking exercise per weekday:

Who exercises:

Dog is walked on: Harness Flat collar Choke chain Halter Pinch collar Off leash Reason:

Training: Dog has been crate trained Dog has attended obedience classes Dog has attended puppy kindergarten Dog has been shown in trials Dog is a trained service dog Dog is trained for other work

Do you still use a crate? Yes If Yes, describe crate:

Location of Crate:

If No, when and why did you stop? Describe the dog’s reaction to being crated.

At what age did puppy/obedience classes start: yrs months Don’t know

Level of training: basic (come, sit, down, heel on leash) average (above plus heel off leash, stay) advanced

Is there any ongoing training? Yes If Yes, describe:

Performance of dog in class/training situation: Don’t know / N/A Poor Fair Good Excellent

Performance elsewhere: N/A Poor Fair Good Excellent

Training aids: Off leash only Halter Pinch collar Flat collar Choke chain Shock collar

Reason:

Which family member(s) have the best control?

Which family member(s) have the least control?

Type of discipline: (indicate dog’s response in space beneath each choice)

none ever startling shake down

response substitution physical roll over

verbal reprimand shock water

distracting time out other

What punishment is most effective?

Does any punishment make the problem worse? Yes

Has punishment ever led to threat or aggression? Yes

Which family member(s) is most successful at punishment?

Type of punishment used:

Which family member(s) is least successful with punishment?

Type of punishment used:

Diet: % Brand/Type (optional)

Canned

Table food

Special Meal

Feeding Schedule: 1x/day 2x/day >2x/day free choice (food available most of the day) Feeding schedule Is consistent Varies

Food treats: type: Contingent on behavior? Yes

Describe how pet eats (slowly, rapidly, etc.):

How would you generally rate the dog’s temperament: Friendly, outgoing Hyperexcitable Fear of noises Aloof, outgoing Supersubmissive Fear aggressive Inhibited Shy with people Offensive aggressive Anxious Fearful (environment) Don’t know

Comments: What was the temperament of the dog as a puppy:

Friendly, outgoing Hyperexcitable Fear of noises Aloof, outgoing Supersubmissive Fear aggressive Inhibited Shy with people Offensive aggressive Anxious Fearful (environment) Don’t know

Comments:

Does your dog regularly (at least weekly) engage in the following:

No When owner present In owner’s absence Don’t (times/week) (times/week) know Excessive barking, whining (_ _) (_ _) House soiling (_ _) (_ _) Destructive chewing (_ _) (_ _) Self licking/chewing (_ _) (_ _) Digging (_ _) (_ _) Pacing, repetitive behavior (_ _) (_ _) Drooling (Excess Salivation) (_ _) (_ _)

OTHER COMMENTS:

Aggression (go to next page - principal complaint - if your dog is exhibiting no aggression). Please consider aggression as any bite, bite attempt, threat, or growling.

Is aggression the primary reason for today’s visit? YES NO Is your dog ever aggressive to members of the immediate family? YES NO If yes, who? Describe:

Is your dog ever aggressive toward people visiting your home? YES NO Were the people? Known Was the dog? Indoors Describe the situations and locations:

Is your dog ever aggressive toward people when off of the property? YES NO Were the people? Known Was the dog? Indoors Describe the situations and locations:

Is there a particular person or type (age, sex, uniform) that your dog is most likely to threaten or bite:

Is there a particular location or situation where aggression is most likely to occur?

Has your dog ever bitten hard enough to break skin or cause injury? YES NO Describe attack:

Describe situations where your dog barks, threatens, or growls, but does not bite:

Does your dog ever display aggression to other animals? YES NO If yes, what animals and in what locations or situations:

When your dog threatens or attempts to bite, how do you handle the situation?

What is your dog’s reaction?

After your dog has bitten, how do you handle the situation?

What is your dog’s reaction?

How would you describe your dog’s attitude at the time of the aggression? (bold, protective, outgoing, fearful, etc.):

How would you describe your dog’s expression and postures at the time of aggression? (cowering, ears back, tail tucked, hackles raised, retreating, hiding):

Principal Complaint: What is the primary problem for today’s consultation (e.g., aggressive, housesoils, destructive, barking, etc.)?

How would you describe the severity of this problem? Mild

Have you considered euthanasia? YES NO Comment:

Describe the most recent incident:

Describe previous incidents:

What age was your pet when this problem started? yrs. mos. Describe the first incident:

How often does the problem occur?

Has there been a recent change in frequency or severity? YES NO If yes, describe:

Describe any changes in the home or the pet’s health when the problem first appeared:

How have you attempted to treat the problem? Describe:

What was the dog’s response?

List any techniques that have had any success:

List any techniques that have made the problem worse:

List any drugs tried so far, and the dog’s response to the medication:

What do you think is the reason for your dog’s problem?

Additional comments on principal problem:

ADDITIONAL PROBLEMS:

YES NO Destructive digging Destructive chewing Barking Howling Whining Housesoiling Urine Housesoiling Stool Stool eating Chasing Hunting/predation Jumps up (owners) Jumps up (guests) On furniture where not permitted Garbage raiding Food stealing Pushy – Wants own way Disobedient: Runs Away Won’t come when called Only listens when feels like it Sexual habits: Masturbation Roaming Mounting Urine marking Chews/licks self Location: Frequency: Tail biting Tail chasing Fly chasing Staring at imaginary objects Uncontrollable urination when excited Uncontrollable urination when frightened Bedwetting (while sleeping) Eats non-food items (Pica) Licks objects Sleep disorders Excitability Overactive Phobias (thunder/cars, etc.) Shyness/timidity (non-aggressive) (eg, ears back, cowering, tail tucked, shaking, retreating, hiding, etc.)

Additional problems (not listed):

PLEASE HAVE YOUR VETERINARIAN COMPLETE AND RETURN YOUR PET’S MEDICAL INFORMATION ALONG WITH ANY RECENT LABORATORY TESTS.

NOTE: THERE WILL BE A $100.00 CHARGE FOR APPOINTMENTS NOT CANCELLED WITHIN 72 HOURS OF SCHEDULED TIME.

GENERAL BEHAVIORAL PROFILE

How does your dog react to the following: happy sub neut fearful def/agg off/agg hyper anx.

 Unfamiliar people at door  Unfamiliar people in home  Same, on neutral territory, on leash  Same, off leash  Same approaching/try to pet, on leash  Babies  Children, 1-6 yrs old  Children, 7-11 yrs old  Children, 12-18 yrs old  Unfamiliar dogs on property  Unfamiliar dogs neutral territory, on leash  Same, off leash  Owners leaving  Owners returning  Nail trimming  Giving medication  Grooming  Bathing  Toweling  Owner reaching over/petting on head  Owner petting dog elsewhere  Owner lifting dog up  Grasping collar, restraining dog  Roughhousing  Walk by food while dog eats  Grab food dish while dog eats  Taking away bone/toy/stolen object  Approach dog on his bed  Disturbing sleeping dog  Stepping over lying dog  Verbal reprimand  Physical punishment  Putting on/taking off collar  Staring at dog  Car rides  Cars, trucks going by  Children on bicycles, roller blades  Joggers (adults)  Vacuum cleaner  Lawn mower  Broom  Thunder  Loud noises (other than thunder)