Date of Consult
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MM
DD
YYYY
Name
*
First Name
Last Name
Email
*
Phone
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(###)
###
####
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Family Veterinarian
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First Name
Last Name
Family Veterinarian Email
*
Family Veterinary Clinic
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Name of Pet
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Breed
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Sex
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Male Neutered
Male Intact
Female Spayed
Female Intact
Age at spay/neuter
Current age of pet
Age of pet when acquired
What is the primary reason for your visit?
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Aggression, destruction, house soiling, barking, anxiety, separation anxiety, other
If Other, describe briefly
How would you describe the problem?
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How would you describe the severity of the problem?
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Mild
Moderate
Severe
Briefly describe the first incident:
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This will be a launching point for discussion. Don't worry about including every detail. Important details: when did this happen, who was there, what was happening, what did your dog do.
Briefly describe the most recent incident:
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This will be a launching point for discussion. Don't worry about including every detail. Important details: when did this happen, who was there, what was happening, what did your dog do.
Does your dog display any of the following behaviours:
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Tail chasing, sucking, star gazing, light chasing, staring, licking objects, self or other
What have you tried to improve this issue?
Have you considered removing your pet from the home if the problem cannot be improved?
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Yes
No
List each family member, along with pets, living in the home with their age
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Are there children who interact with your dog regularly?
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Yes
No
At what age was this pet enrolled in obedience training?
Who was the instructor/facility/company?
What type of training have you enrolled your pet in?
rewards, clicker, dominance/balance, corrections, other
If other, describe briefly
Please list any dog walkers, daycares, groomers or other professionals who interact with your dog
Has your dog ever growled at a
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Select all that apply (person, dog, cat)
Has your dog ever attempted to bite
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Select all that apply (person, dog, cat)
Has your dog ever bitten a
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Select all that apply (person, dog, cat)
If yes to any of the above, would you describe the aggression as
Getting better
Staying the same
Getting worse
N/A
Can you predict when aggressive behaviour will occur?
Yes
No
N/A
Which of the following describes you dog's aggression
Single bite that does not break skin, single bite that breaks skin, multiple bites but stops, multiple bites and holds on
Has your dog ever caused sufficient injury to require medical attention?
Yes
No
If yes, briefly describe
Have you ever used any of the following tools/techniques with your dog?
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Select all that apply, including if used in the past.
List any noises or situations your dog is afraid of
How long does it take for your dog to settle back to normal?
Do any of the following problems arise when your dog is without a human in the home?
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Vocalize excessively, destroy objects, urinate/defecate, salivate excessively
How does your dog react when you prepare to leave?
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How does your dog react to home comings?
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Is your dog completely house trained?
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Yes
No
If no, what do you do if your dog eliminates in the incorrect location?
Does your dog have any current or ongoing medical issues?
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Yes
No
If yes, describe:
How does your pet react at the veterinary clinic?
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What do you feed your pet?
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Do you consent to having photos or videos of your pet shared for educational purposes?
*
