This form is specific to patients experiencing behavioral issues. Only submit this form if you currently have a scheduled 'Behavior Consultation Appointment' to address BEHAVIOR PROBLEMS. (aggression, destructive behavior, anxiety, etc.)

Client Information

Client First Name

Client Last Name

Phone Number

Email

Patient Information

Patient Name

Species

Breed

Color

Patient Age (Years/Months)

Select all that apply

Male

Female

Spayed/Neutered

Intact

What age was the pet when you got it?

Where did you get this pet from?

friend, breeder, pet shop, humane society, other

Time spent Indoors

From 0-100%: How much time, per day, does your pet stay inside?

Time Spent Outside

From 0-100%: How much time, per day, does your pet stay outside?

Is the pet left alone without Supervision? If yes, how long?

How many hours per day is the pet alone? If not alone, put N/A.

In what area of the house or yard is the pet kept when the family is at home? (multiple choice, select all that apply)

In what area of the house or yard is the pet kept when the family is not home? (multiple choice, select all that apply)

In what area of the house or yard is the pet kept when the family is asleep? (multiple choice, select all that apply)

In what area of the house or yard is the pet kept when guests are visiting? (multiple choice, select all that apply)

Does your pet have access to a yard through a Dog/Cat door?

Describe your pet's personality. Give details

Describe your pet's behavior when guests are present.

Calm, Anxious, Destructive, Whining, etc.

What do you feed your pet? How much?

Who feeds your pet?

List Current Medications (Medication, Concentration, Dose, Frequency)

Ex: Carprofen 100mg- 1/2 tablet twice daily

When was the behavioral problem first noted?

Ex: 3 years ago

Where and under what circumstances was the problem noticed?

Ex: When a guest came to the house. When I left the house and let "snoopy" free roam the house. At the dog park with multiple dogs, etc.

Describe a situation(s) in which the problem is likely to occur.

Ex: When I leave "snoopy" unattended at home, alone.

What is the Frequency of occurrence?

(Ex: 2 times per week, per month, At random)

Has there been a change in frequency of occurence?

YES

NO

NOT SURE

Has there been a change in the appearance of the problem? (worsened aggression, destructive behavior, etc.)

YES

NO

UNSURE

If YES to either, explain with detail. If NO change, put none.

Corrective Measures

Has anything been done to correct the behavior(s)?

Explain with detail, what has been done to correct the behavior. (training, medication, discipline, confinement, etc.) If nothing has been done put 'nothing'

What was the pet's response to the measures taken to correct the behavior?

Were there significant changes in the pet's environment or routine, that coincided with the behavior(s) noted (select all that apply)

Select all that apply.

With detail, explain all situations that will elicit the negative behavior(s) noted.

(Ex: When children are around, only at home when guests come over, in public, when left alone, at random)

If your pet is experiencing aggressive behavior, please, explain in detail an experience you had with your pet when he/she became aggressive. (if not applicable put N/A)

Use this field, freely, to add any additional information you feel is important.

Elimination Habits

Does your pet inappropriately urinate inside your home?

YES

NO

Other

Does your pet inappropriately defecate inside your home?

YES

NO

Other

If so, explain where the pet may choose to urinate/defecate inside your home

(ex: rugs, beds, walls, anywhere and everywhere)

Litterbox Availability

Litterbox Cleanliness

How often is the litter replenished with fresh litter?

Medical History

Explain prior medical history. (UTI, Thyroid Disease, Bad Attitude Syndrome (joking) If none, put none

Upload Medical Records, Audio, Videos or Pictures that may be helpful. If files are too big you may email files to rollinpaws@outlook.com