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609.259.8300
315 Robbinsville-Allentown Rd., Robbinsville, NJ 08691
2834 Route 73N, Maple Shade, NJ 08052
507 Route 70, Brick, NJ 08723

Canine Behavior Questionnaire



Client Information


Mr.     Mrs.     Ms.

Owner's Last Name*

Owner's First Name*

Spouses's Last Name

Spouses's First Name

Address*

City*

State*

Zip Code*

Phone #*

Mobile

Work

Emergency

E-mail

Pet Information


Pet's Name*

Breed*

Dog     Cat
Other

Male    Neutered
Female    Spayed

Age*

Color*

Method of Payment


Cash     Check     Credit Card     Check Card

Check Writing Information (if writing a check)


Driver's License #

State

Owner's DOB

Veterinarian Information


Name of your Veterinarian and Facility

Telephone #

How did you hear about our hospital?
Vet Referral
Yellow Pages
Internet Search
Friend
Other

I hereby irrevocably consent to the use of any images in any and all marketing materials for NorthStar VETS, authorized by NorthStar VETS.
Yes     No

Household Information


People Living in household (Please list names,age and relationship e.g. spouse, partner, son, daughter, roommate, etc.)

Other people in regular contact with pet (e.g. petsitters, housekeepers, friends, etc.)

Other pets in household (in order came into household)

Type of house
Single Family Detached
Apt.
Attached house (townhouse, rowhouse)
Other

How long have you lived in this house?

Since adoption, how many houses have you and your dog lived in?

Do you have a yard?
Yes     No
If yes, how big is the yard?

Is the yard fenced?
Yes     No
If yes, approximate fenced yard

Type of fence?
Wooden Slats
Height
Solid Wall
Height
Chain Link
Height
Electronic/Invisible
Height
Other

Acquisition Information


How long have you owned this dog?

How old was the patient when acquired?

Where did you obtain this dog?
Performance breeder (e.g. show, hunting, agility, etc)
Hobby breeder
Private home/previous owner
Shelter/rescue organization
Pet Store
Other

Behavior of dog's parents/littermates (if known)

Describe previous home(s) (if known)

If a shelter/rescue adoption describe information you were given about dog's behavior/experiences before adoption (including foster homes)

Why did you choose this breed of dog?

Why did you choose this individual dog?

Neutering Information


Is this dog Neutered/Spayed?
Yes     No
If yes, at what age?

Reasons for neutering/spaying (check all that apply)
Prevent behavior problem
Health/Vet recommended
Population control/don't plan to breed
Adoption agreement

Correct existing behavior problems
(list problems that dog had before neuter that you hoped to correct with surgery)

Other

Did you notice any changes after neutering/spaying (please describe)?
Yes     No
If yes, please describe

If not neutered, reasons for not neutering (check all that apply)
Show dog
Plan to breed
Health concerns
Other

Medical Information


Current Weight

Vaccination
Rabies

Other vaccinations

List any major illnesses/surgeries (dates)

List all medications/treatments your dog is currently receiving including heartworm, flea/tick preventatives/collars, dietary supplements, herbal/homeopathic treatments

Please copy name from medication labelstr for accuracy

Daily Activities and Routine


Meals - Types of food

Dry    % of diet

Canned    % of diet

Raw    % of diet

People food    % of diet

Other

If you feed a special diet (e.g. hypoallergenic, grain free, prescription diet) why?

Eating habits (check all that apply)
Eats right away
Picky eater
Anxious eater
Guards food from people
Guards food from dogs
Guards food from other pets
Other

Feeding (check all that apply)
Fed alone (e.g. separate room, crate)
Fed near other pets
Fed from food dispensing toys or slow feeders
Person stays nearby when dog is eating
Hand feed most/all meals

Sleeping

Where does your dog sleep at night?

Where does your dog sleep during the day?

If disturbed while sleeping what is your dog's reaction (check all that apply)?
Happy     Startled     Growls     Barks
Bites     Scared     Grumpy     Playful
Other

Have you made any changes in where your dog sleeps because of these reactions to being disturbed?
Yes     No
If yes, please describe

Exercise

Does your dog get regular leash walks?
Yes     No

If NO, why (check all that apply)?
Doesn't walk well (pulls) on leash
Aggressive on walks
Don't have the time
Medical reason (person)
Medical reason (dog)
Other

If YES, who takes the dog for leash walks?

How often?

How long are the walks?

Location (e.g. around neighborhood, in town, in park)

What do you use to walk the dog (check all that apply):
Flat buckle collar
Body Harness
Head collar (Halti, Gentle Leader)
Front attach harness (Easy Walk, Freedom Harness,)
Training/choke collar
Prong collar
Remote collar
Retractable leash
Long leash (6ft + )
Average leash (4-6ft)
Short leash (4ft or less)
Other

How is your dog on leash?
Excellent (never pulls, pays attention to me)
Good (rarely pulls)
Fair (pulls but I'm able to control)
Poor (pulls a lot, difficult to control)
Bad (pulls, I don't enjoy the walks)

Off-leash Exercise: Does your dog get off-leash exercise?
Yes     No

If Yes, who takes the dog for off-leash exercise?

How often?

For how long?

Locations (e.g. trails, dog parks, beaches, yard)

Play

Does your dog play with toys? Yes     No

What are your dog's favorite toys? (check all that apply)
Balls
Stuffed animal
Rope toys
Soft squeaky toys
Frisbee
Hard chew toys
Tug toys
Rubber toys (e.g. Kong)
Other

How does your dog play with toys? (check all that apply):
Tug games with people
Tug games with other dogs
Chase games with people
Chase games with other dogs
Shakes and "kills" toys
Chews toys
Other

How often does your dog play with toys?
Several times/day
Once daily
Several times/week
Weekly
Rarely
Never

How often does your dog play with people?
Several times/day
Once daily
Several times/week
Weekly
Rarely
Never

How often does your dog play with dogs?
Several times/day
Once daily
Several times/week
Weekly
Rarely
Never

Living Spaces/Being Left Alone

Where does your dog spend the most time when people are home:
Loose in house (with access to outside)
Confined (e.g. with gates) to part of the house (with access to outside)
Inside in a crate or pen
Loose in the yard
Outside in a kennel or pen
Other

Where does your dog spend the most time when people are not home?
Loose in house(with access to outside)
Confined (e.g. with gates) to part of the house (with access to outside)
Inside in a crate or pen
Loose in the yard
Outside in a kennel or pen
Other

How long is your dog left alone on an average day?

When is your dog left alone (e.g. 8:00am-5:00pm)?

What is your dog's reaction to being left alone (check all that apply):
Calm
Depressed
Barks
Cries/howls
Urinates/defecates
Escapes Destructive
Anxious
Excited
Aggressive

If there will be or have recently been any major changes to the daily routine (e.g. vacations, owner who travels for business, etc.) please describe.

Training

Has your dog had any training?
No
Yes
Trained Ourselves
Classes/Met with Trainer
Already Trained

What type of training and at what ages (For example: puppy class 8-16 weeks old, group classes 1 year old)

Puppy classes:

Group classes:

Private lessons:

Board & train:

Other:

Name(s) of instructor(s)/school(s):

What training techniques have you used (check all that apply):
Training collar (choke)
Food rewards
Verbal Praise
Play/toys
Prong collar
Remote collar (shock, vibration, citronella)
Bark collars (shock, vibration, citronella)
Other

Who in the household trained the dog?

What commands does your dog know?

Has your dog won any titles (agility, obedience, CGC)?
No    Yes
If yes, please describe

Did your dog enjoy training?

How well does your dog obey commands without distractions:
Very well
Well
Fair
Poorly
Does not follow commands

How well does your dog obey commands with distractions:
Very well
Well
Fair
Poorly
Does not follow commands

How does dog react to following:

Unfamiliar people at door to house
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite     Don't Know    Don't Do

Unfamiliar people in home
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite    Don't Know    Don't Do

Unfamiliar people, away from home, while on-leash
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite     Don't Know    Don't Do

Unfamiliar people away from home while off-leash
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap        Don't Know    Don't Do

People on bicycles, roller blades, etc
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite     Don't Know    Don't Do

Joggers (adult)
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Cars/trucks going by, while on leash
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite     Don't Know    Don't Do

Babies
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite     Don't Know    Don't Do

Children
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite    Don't Know    Don't Do

Unfamiliar dogs, when your dog is on leash
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite     Don't Know    Don't Do

Unfamiliar dogs, when your dog is off-leash
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite     Don't Know    Don't Do

Squirrels/cats/small animals
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Dog in yard-person passes
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite     Don't Know    Don't Do

Veterinarian's office
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap     Bite    Don't Know    Don't Do

Stranger approaching car when dog is inside
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite     Don't Know    Don't Do

Thunder
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Loud noises
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

How does dog react to a family member doing the following:

Walk by food while dog eats regular meal
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Reach for or take food dish while dog eats regular meal
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Walk by while dog eats more delicious food
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Reach for/take away non-edible toy (e.g. ball, stuffed animal)
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Reach for/Take away edible bone, rawhide
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Take away stolen non-food item (e.g. socks)
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Take away stolen food item (including dirty tissues, paper towels, food wrappers)
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Reach for dropped food at same time as dog
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Reach over head/pet on top of head
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Pet on other parts of body
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Brush
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Bathe
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

How does dog react to a family member doing the following:

Pick dog up
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Put on/off collar
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Put on/off leash
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Disturb while sleeping
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Move while on furniture
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Dog is sitting with one family member and another family member approaches
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Hold back when excited (e.g. from running out door) NOT WHEN AGGRESSIVE
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Hold back when aggressive (e.g. barking at another dog)
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Verbal reprimand
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Leash correction
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Physical reprimand
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Staring at dog
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

How does dog react to a dog in the household
(if your dog doesn't regularly spend time with another dog you don't need to fill out)

Around regular food
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Around rawhides
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Around treats
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Around toys
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Around favorite people
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

While on walks together
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

During play
Happy     Neutral     Fearful/Anxious/Submits     Snarl    Growl
Bark    Snap    Bite    Don't Know    Don't Do

Bite History

Has your dog ever bitten a person?
No     Yes

If yes, please describe IN DETAIL when the bite happened (approximate date is ok), who was bitten, what the circumstances of the bite were. Please answer separately for EACH BITE.

How bad was the worst bite your dog ever gave to a person (check all that apply):
Made contact but didn't leave a mark
Small red mark
Bruised, didn't break skin
Broke skin, minor scrape
Broke skin, punctures
Multiple punctures
Punctures and tore flesh
Multiple bites at one time
Required emergency treatment

Have any bites been reported to Animal Control or other authorities?
No     Yes

Have any victims threatened/taken legal action because of an aggressive incident?
No     Yes

Primary Behavior Problem

(please fill out this section in detail, it will allow us to spend more time during the appointment discussing treatments instead of going over your dog's history):

What is the ONE main behavior problem you wish to address?

Describe the very first incident of this problem.
Try to remember the earliest occurrence of the problem, even if it wasn't as serious as it is now. For example, if your dog is aggressive to people, describe the first time she growled or barked at someone, not the first bite. Or if your dog has problems being left home alone, describe the first time he whined and cried when you left, not just the first time he ripped up the carpet.
Include:
Where the incident occurred
Who else (human and animal) was present
What happened just before the incident,
How everyone present reacted.
If you noticed any changes in your dog's body language or facial expression before, during or after the incidents please describe.

Date of FIRST INCIDENT and dog's age at the time (approximate date/age is ok):

Description:

Describe per instructions above MOST RECENT incident

Date of incident:

Describe per instructions above at least one other incident you feel illustrates the problem behavior
(if you would like to describe other incidents, that's great!)

Date of incident:

Description

Frequency of Primary Behavior Problem:

How frequently does this problem occur?
>10 times/day
1-10 times/day
1-6 times/week
<1x/week
<1 time/month

Is the frequency...
Increasing
Decreasing
Unchanged

What percent of time that your dog is in a potentially problematic situation does the problem behavior occur?
<25%
25-50%
51-75%
76-100%

WHAT HAVE YOU TRIED TO DO TO CORRECT THIS BEHAVIOR PROBLEM AND HOW DID YOUR DOG RESPOND? Please include training, management and MEDICATIONS
Example: Scolded him when he growled. He continued to growl and started to bark also.

How serious do you and other members of the household find this problem
Please include name and whether they feel the behavior is mild, moderate, severe or intolerable

Has anyone suggested you euthanize or rehome this dog because of this problem
(this is not a recommendation, we just want to know what has been suggested)?
Euthanize Rehome Neither

Have you ever considered euthanasia or rehoming your dog because of this problem?
Euthanize Rehome Neither

List other problem behaviors in order of importance to you.