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 Initial Consultation Request Form to 1-508-839-8734. If you have questions, call 1-508-887-4640.
| Date:
|
Recorder: |
| Name
& Address of owner: |
| 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 interrupted when engaged in the
behavior? |
| How
long is the interval between the behavior
stopping and the beginning of the next occurrence? |
| Describe
any methods used to stop the behavior and
the dog's response to these methods: |
| Please
give a detailed description of the last
time this problem 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: |
| Describe
interactions between the animals in the
household: |
| Describe
interactions between the dog and family
members: |
| 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: |
| 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?: |
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 Jeckyl and Hyde personality? |
| Do
you consider your dog hyperactive? |
| 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)? |
|
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Thank
you for using PetFax.
|