Aggression Consultation Aggression Consultation "*" indicates required fields Step 1 of 6 16% Name* Address* City* Zip code* Email* Occupation* Home Phone*FaxVeterinarian/Clinic* Clinic phone/fax if knownReferred ByPET INFORMATIONPet’s name* Breed* Color* Age* Weight* Sex* Male Female Neutered* Yes No Age neutered | Any change after neutering?Age Obtained* Where did you obtain this pet?* Breeder, if applicablePlease describe the behavior of parents and/or littermatesREASON(S) FOR PRESENTATION Please list behavior problems in order of importance: (realize that some cases have multiple issues and may have to be addressed separately)Describe the problem behavior Intensity Severe Moderate Mild Length of time problem has existed Frequency of problem (eg.once weekly, daily) Add 2nd Issue Yes No Describe the problem behavior Intensity Severe Moderate Mild Frequency of problem (eg.once weekly, daily) Length of time problem has existed Add 3rd Issue Yes No Describe the problem behavior Intensity Severe Moderate Mild Frequency of problem (eg.once weekly, daily) Length of time problem has existed INFORMATION ON PRESENTING COMPLAINT(S)What do you think has caused the problem(s)?Describe the problem/misbehavior – last incident: (make sure to include such descriptions (if possible) of the dog’s body posture, locations of other people or animals in the vicinity, circumstances that you believe stimulated the problem, etc)Describe previous incidents?Has there been a recent change in frequency of the behavior? What has been done so far to try and correct the problem?What has been the dog’s response?List any techniques that have been successfulList any techniques that have made the problem worseList any drugs that have been tried so far and the dog’s response to the medicationMg strengthDrugFrequency (e.g. once a day, twice a day)Length of time drug administered (e.g. days, 2 weeks, 1 month)Outcome (successful or not) Add RemoveList any other dietary treatments, supplements or remedies and the dog’s response:FAMILY / RELATIONSHIPSList each family member living in the home with the pet (include sex and age)Member NameSexAge Add RemoveHow does your dog get along with each family member?Who feeds?* Who plays?* Who grooms? Who trains? Who gives treats? Who exercises/walks? Briefly describe the family schedule, including how long the dog is left alone:List the pets in your household:NameSpeciesBreedSex Spayed/neutered?Age obtainedAge Now Add RemoveHow do the pets get along with each other? TRAININGAny formal training?* Yes No Class* Private instructor Trained at home How successful was training? Is there any ongoing training?* Yes No Describe Type of training collar used: | Dog’s responseNeck collar Remote collar (if yes, indicate type e.g. shock, citronella, etc) Head halter (such as Gentle Leader®, Halti®) Body Harness Other (choke, pinch, prong) How would you describe the training? Reward-based Assertive/dominance Aversive/mostly corrections Other How well does your dog obey the following commands (when asked for the FIRST time) for each household member? (list as a percent)How well does your dog obey the following commands (when asked for the FIRST time) for each household member? (list as a percent)Household memberSitDownStayCome Add RemoveAre there any other commands or tricks your dogs knows?PunishmentPhysical punishment Yes No Reaction to physical punishment Noise punishment (shaker can, noise) Yes No Reaction to noise punishment Ultrasonic (e.g. Petagree®) Yes No Reaction to Ultrasonic Water Sprayer Yes No Reaction to Water Sprayer Verbal reprimands Yes No Reaction to Verbal reprimands Physical handling: muzzle grasp pinning Yes No Reaction to Physical handling: muzzle grasp pinning Time out Yes No Reaction to Time out Booby traps/repellents Yes No Reaction to Booby traps/repellents Handling How does your dog react to the following types of handling?Nail trimming Giving pills Brushing Hugging/kissing Rubbing belly Patting head Grabbing collar Lifting Rolling over Bathing Medical ScreenAre there any past or present illnesses?Any painful conditions?* Yes No Please describe Diet: (Brand, dry/canned)* Describe appetite* Voracious Normal Finicky Decreased Any changes in stool?* Any change in drinking?* More Less Same Any change in urination?* Same More frequent Less frequent Larger volumes Smaller volume Any food intolerance?* Yes No Is your pet on any other medications? (besides the drugs listed under primary behavior complaint ) Make sure to include supplementsIs your pet on any other medications?DRUG NAMEDOSAGEFREQUENCY GIVEN (times per day)DURATION OF MEDICATION Add RemoveREINFORCEMENT ASSESSMENT If your dog were allowed to have any treat, what would he/she prefer?*List top five: Add RemoveWhat other types of rewards does your dog enjoy?*(play toys, walks, attention / affection). List top five: Add RemoveHOUSE TRAINING SCREEN (If your pet is not housesoiling, skip this section)Was your dog ever completely house trained? Yes No At what age was he/she considered house trained? How often does your pet house soil? (ie. several x/day, weekly or monthly?Is it urine, stool or both?When is the dog most likely to house soil? Do you have a doggie door? Yes No Does your dog use the doggie door? Yes No In what rooms does your dog tend to soil? Is there a room/location in which the dog does NOT soil? Does your dog soil when family members are home? Does your dog soil directly in front of a family member? What do you do when you find urine or stool in the improper location? Does your dog urine mark? (urinate on upright objects) How many times per day does your dog have a chance to go outside to eliminate? How long is the longest confinement without access to outside? (if any) Is your dog crated? Yes No Is there ever urine in the crate? Yes No Does your dog leak urine when Sleeping? Walking? Approached by owner? If approached by stranger? Excited? Frightened? Departure Behavior ScreenHow long is the dog left alone on an average day?* Is the dog left* Indoors Outdoors Access to both Is your dog crated or confined on departure?* If crated, describe crateLocation of crate? If confined other than crate, describeHas your dog been left at a kennel, veterinary clinic or with family/friends?If yes, describe your dog's reactionDoes your dog exhibit any problem behaviors on your departures?* Yes No If yes, continue with following questions, if no, please skip to the next section:Describe your dog's behaviors when left alone:Does the behavior differ depending on length of departure or the time of day left alone?How does your dog act as you or other family members are getting ready to leave? Describe:Does the behavior differ depending on who is the last to leave the home?How does the dog react when the family returns?Have you ever left the dog alone in the car? If so, how did he/she react?AGGRESSION SCREEN Has your pet displayed any of the following? Threatening behavior?* Yes No Growling?* Yes No Bite attempts?* Yes No Bites?* Yes No If your pet has displayed any of the above, but they have been resolved, or controlled to your satisfaction, then skip next section and proceed to the next: Situations that lead to aggression (check all that apply) Petting/handling Growled Attempted to Bite Bit No Reaction Explain Eating or being approached while eating Growled Attempted to Bite Bit No Reaction Explain Chewing stolen toys/objects attempting to take away from dog Growled Attempted to Bite Bit No Reaction Explain Trimming nails/bathing/brushing Growled Attempted to Bite Bit No Reaction Explain Staring at dog Growled Attempted to Bite Bit No Reaction Explain Scolding dog Growled Attempted to Bite Bit No Reaction Explain Leash or collar correction Growled Attempted to Bite Bit No Reaction Explain Physically reprimanding dog Growled Attempted to Bite Bit No Reaction Explain Raising hand over dog Growled Attempted to Bite Bit No Reaction Explain Bend or lean over dog Growled Attempted to Bite Bit No Reaction Explain Hug or kiss dog Growled Attempted to Bite Bit No Reaction Explain Grabbing collar Growled Attempted to Bite Bit No Reaction Explain Rolling over Growled Attempted to Bite Bit No Reaction Explain Disturbing while sleeping Growled Attempted to Bite Bit No Reaction Explain While dog is on furniture/bed, attempting to remove dog Growled Attempted to Bite Bit No Reaction Explain Aggression towards people: If your pet is not aggressive towards people, skip this section and move to the next:In your opinion, what is the potential for injury to another person?Has your dog ever bitten hard enough to break skin or cause injury? Yes No Describe Number of bites that have broken skin?Total # of bitesBody parts typically bittenIf your dog has bitten a person, how old was the dog the first time he/she bit?MonthsYearHas your dog ever been aggressive toward members of the immediate family? Yes No Describe Is your dog ever aggressive toward visitors? Yes No Describe Is your dog aggressive toward people off property? Yes No If yes, were the people known, strangers or both? Explain Is there a particular person or type (age, sex, uniforms) that you dog is most likely to threaten or bite? Yes No Describe Is there a particular location or situation where aggression is most likely to occur? Yes No Describe When your dog threatens, attempts to bite or bites, how do you handle the situation and what is the dog’s reaction?How would you describe your dog’s attitude at the time of aggression? (bold, protective, fearful, etc)How would you describe your dog’s expression and postures at the time of aggression? (hackles raised, ears forward or tail back, tail up or tucked between legs and under, cowering, running forward and then retreating):Aggression towards other dogs If your dog is not aggressive towards other dogs, skip this section and move to the next:In your opinion, what is the potential for injury to another dog?How old was your dog when you first noticed aggression to other dog(s)?MonthsYearsHas your dog ever bitten hard enough to break skin or cause injury requiring medical attention? Yes No Describe Number of bites that have broken skin?Total # of bitesBody parts typically bitten Add RemoveIs there a particular location or situation where aggression is most likely to occur? Yes No Describe Aggression toward other dogs, check all that applyAggression toward other dogs Investigates the other dog before attacking Tries to attack from a distance What is the usual distance away from another dog when attempting to attack? Barks/growls before attacking Does not bark or growl before attacking Gives body language such as stiffening, hair raising and staring before attacking Attacks only bigger dogs Attacks only smaller dogs Size of the dog does not matter Attacks only female dogs Attacks only male dogs Gender of the dog does not matter Bites once and retreats Bites multiple times and retreats Bites and does not let go Additional Behavior ProblemsDestructive chewing Yes No Describe Barking Yes No Describe Whining Yes No Describe House soiling urine Yes No Describe House soiling stool Yes No Describe Stool eating Yes No Describe Jumps up (owners) Yes No Describe Jumps up (guests) Yes No Describe Garbage raiding Yes No Describe Food stealing Yes No Describe Pushy – wants own way Yes No Describe Only listens when feels like it Yes No Describe Sexual habits: Masturbation, Roaming, Mounting, Urine Marking Yes No Describe Chews/licks self: (if a problem, note location on body and frequency) Yes No Describe Tail biting Yes No Describe Imaginary fly chasing Yes No Describe Staring at / chasing imaginary objects Yes No Describe Hunting / predation Yes No Describe Uncontrollable urination when excited Yes No Describe Uncontrollable urination when frightened Yes No Describe Bedwetting (while sleeping) Yes No Describe Eats non-food items (Pica) Yes No Describe Licks objects Yes No Describe Excitability Yes No Describe Overactivity Yes No Describe Phobias (thunder / cars etc) Yes No Describe Shyness / timidity (nonaggressive) Yes No Describe Additional problems not listed Yes No Describe CAPTCHA
