PETFAX Canine Fax Sheet

The owner(s) should fill out the following form thoroughly yet concisely. PLEASE ANSWER EACH QUESTION DIRECTLY ON THIS FORM IN THE SPACE PROVIDED. LIMIT ADDITIONAL INFORMATION TO ONE TYPEWRITTEN PAGE IF NECESSARY. If the dog appears anxious when the owner leaves the dog (separation anxiety) please also fill out the last section. Print out and fax both the completed Behavior Fax Sheet and the Initial Consultation Request Form to 1-508-839-8734. If you have questions, call 1-508-887-4640.

Date:	Recorder:
Name & Address of owner:
Email:
Telephone:	Fax:
Name of dog:	Breed:
Age of dog:	Age at which dog was obtained:
Weight:                        Sex:	Color:
Spayed/Neutered:	Age of neutering:
Reason for neutering:
Any behavioral changes following neutering?
Date of last physical examination: (Please include copies of any relevant medical records and/or blood work.)
Any medical problems?
Any current medications (please include dose if known)?

WHAT IS YOUR DOG'S BEHAVIOR PROBLEM?

Age of onset:

Duration of each incident:

Frequency of occurrence:

Have there been any changes in the pattern, frequency, intensity and/or length of incidents from the time of onset to the present?

Are there any specific conditions which seem to trigger the behavior?

Can the dog be verbally or physically interrupted when engaged in the behavior?

Please indicate if you have previously tried any of the following treatments for this problem: (check all that apply)

□ Avoiding the behavior	□ Nothing in Life is Free	□ Increased exercise	□ Shock collar
□ A head halter (e.g. Gentle Leader)	□ Dog Appeasing Pheromone	□ Environmental enrichment	□ Independence training
□ Herbal supplement(s)	□ the Anxiety Wrap	□ Ignore my dog	□ Pinch or prong collar
□ Homeopathic product	□ Obedience Training	□ Give my dog a time-out	□ Other:
□ Prescription medication(s)	□ Tellington Touch	□ Tell my dog “No!”
□ Hit my dog	□ Desensitization	□ Counterconditioning

Please describe your dog’s response to the treatments that you’ve previously tried:

Have you previously enlisted the help of a trainer, behaviorist or veterinarian for help with this problem?

If so please list their credentials:

Please give a detailed description of the LAST time this problem occurred:

Please give a description of the FIRST time this behavior occurred:

DOG'S HISTORY

Where did you get the dog from:

At what age:

Do you know if the dog's parents or siblings engaged in similar behaviors or in any other abnormal behaviors?

List people living in the house with the dog, include children's ages:

List other animals in the household, their species, breed, age sex and whether or not they are neutered, please indicate which of these animals were living in the house when this dog was acquired:

Briefly describe your pet’s relationship with other pets in the house:

Briefly describe your pet’s relationship with people living in your home:

How does the dog react to strangers?

Behavior of the dog in the veterinary office and during examination:

Does the dog live primarily inside or outside? Describe any restrictions to dog's movements inside the house/kennel etc:

Do you have a fenced-in yard or the Invisible Fence?

DAILY ACTIVITIES

Please describe a typical 24 hour period in your dog's life, start with where and when the dog wakes up in the morning:

DIET

Type of food:

Frequency of feeding, and the amount fed:

Other food/treats/table scraps:

EXERCISE

On leash, include location:

Off leash, include location:

Time spent playing actively with owner. Describe activities which take place:

Time spent actively playing with other animals:

OBEDIENCE TRAINING

Have you attended obedience classes with your dog? If so, please describe the classes:

Does your dog do the following willingly (check where appropriate):

____ sit	____ stay	____ down	____ heel
____ come	____ stand for grooming	____ fetch	____ do tricks

Situations in which your dog is less likely to obey you:

Does your dog work well for (check where appropriate)?:

____ food	____ ball/Frisbee/retrieve game	____ no reward
____ praise	____ petting

INTERACTIVE BEHAVIOR

Does your dog demand to be petted?

Does your dog ever seem irritated by or resent petting?

Does your dog bark excessively?

Does your dog cower or run away if people talk loudly or act boisterously?

Does your dog ever urinate or roll over on his/her back when greeting you?

Does your dog ever urinate or roll on his/her back when greeting strangers?

Does your dog urinate or roll on his/her back when greeting strange dogs?

Is your dog comfortable in crowds?

How does your dog act when strangers come to the house?

How does your dog act when he meets or passes strangers away from the house?

How does your dog act when he meets strange dogs?

1. When both are on the leash:

2. When both are off leash:

3. When he is leashed and other dog is free:

Is your dog frightened excessively by anything (check)?

____ thunderstorms      ____ flies    ____  gunshots
____ other (specify)_______________________________________________

Does your dog chase (check)?

____ running child(ren)     ____ jogger    ____ bicyclist   
____ cats or other furry animals cars

Does your dog urinate/defecate in the house?

Please check the appropriate box if your dog exhibits any of the listed behaviors at any time when you or any member of the family do the following:
	Growl	Lift Lip	Snap	Bite	No aggressive response	Not tried
Touch dog's food or add food while eating
Walk past dog while eating
Take away real bone, rawhide, or delicious food
Walk by dog when s/he has a real bone/rawhide
Touch delicious food when dog is eating
Take away a stolen object
Physically wake dog up or disturb resting dog
Restrain dog when it wants to go someplace
Lift dog
Pet dog
Medicate dog
Handle dog's face/mouth
Handle dog's feet
Trim the dog's toenails
Groom dog
Bathe or towel off
Take off or put on collar
Pull dog back by the collar or scruff
Reach for or grab dog by the collar
Hold dog by the muzzle
Stare at the dog
Reprimand dog in loud voice
Visually threaten dog: newspaper or hand
Hit the dog
Walk by dog in crate
Walk by/talk to dog on furniture
Remove dog from furniture: physically or verbally
Make dog respond to command
Does your dog get a glazed look in his/her eyes?
Does your dog have a Jekyll and Hyde personality?
Do you consider your dog hyperactive?

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SEPARATION ANXIETY:  Please complete this page if your dog has ever exhibited a problem behavior when left alone or appeared excessively anxious when you prepare to leave.
History	Yes	No	I don't know
Did you acquire your dog after 3 months of age?
Did you acquire your dog at 5 weeks of age or less?
Was your dog acquired from a shelter or a pound?
Has your dog had multiple owners during his/her life?
Was your dog acquired from a pet shop?
Was your puppy an orphan or hand raised?
Was your dog the single puppy in a litter?

Behavior	No	Mild	Moderate	Severe
Does your dog follow you around the house?
Does your dog become anxious at the sound of car keys?
Does your dog become anxious when you put on your coat or shoes?
Does your dog become aggressive when you leave?
Does your dog exhibit other problem behaviors as you prepare to leave?
Does your dog bark or whine excessively within 30 minutes of your departure?
After you leave does your dog's activity decrease?
After you leave does your dog appear depressed?
After you leave does your dog have a loss of appetite?
Only in your absence does your dog destroy property?
Only in your absence does your dog urinate or defecate in your home?
Does your dog regularly have diarrhea, vomit, or lick excessively in your absence?
Does your dog exhibit an excessive greeting on your return (jumping, hyperactivity, barking, more than 2-3 minutes)?

Please indicate whether your dog does the following in response to noises.

A) Destruction

1 Mild damage (destroys small items)

2

3

4

5 Extensive damage (e.g. holes in wall, etc)

B) Elimination (Check one): ____ Urination, _____Defecation, _____Both

1 Infrequently housesoils during a noise event

2

3

4

5 Frequently housesoils during a noise event

C) Salivation

1 Damp around mouth

2

3

4

5 Wet around mouth and forepaws

D) Vocalizations (Check all that apply): _____Howl, ____Bark, _____Whine ____)Other(describe):

1 Vocalizes for a short time during the event

2

3

4

5 Vocalizes during the entire event

E) Hiding If yes, where?

1 Spends a short time hiding

2

3

4

5 Hides throughout the entire event

F) Pacing

1 Spends a short time pacing

2

3

4

5 Paces throughout the entire event

G) Panting

1 Pants for a short time during the event

2

3

4

5 Pants throughout the entire event

H) Remains near owner

1 Remains near owner for a short time during the event

2

3

4

5 Remains near owner throughout the entire event

I) Self-damaging behavior

1 Mild damage (e.g. licking feet etc)

2

3

4

5 Extensive trauma (e.g. broken teeth, nail etc)

J) Trembling

1 Trembles for short times

2

3

4

5 Trembles throughout the entire event

K) Other (describe)

1 Small amount

2

3

4

5 Extensive amount

Please provide the following information about your dog’s local veterinarian:

Name:

Business Address:

Phone Number:

How did you hear about Tufts Animal Behavior Clinic and the Petfax service?:

Thank you for using PetFax.

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