Separation Anxiety Questionnaire Separation Anxiety Questionnaire "*" indicates required fields Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Occupation Phone*Veterinarian/Clinic* Clinic Phone (if known)Referred By Pet InformationPet's Name* Breed* Age* Sex* Male Female Neutered* Yes No Age Obtained* Where did you obtain this pet?* Breeder (if applicable) Is your dog on any medication? Yes No Please Describe MedicationHow 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?* Crated Confined 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? Yes No Describe your dog's reactionDoes your dog exhibit any problem behaviors on your departure?* Yes No If yes, when did this behavior start?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?How long would you like to be able to leave your dog alone? Do you have family, friends or a daycare facility who might be able to help with your dog while in training? Yes No Please describeHave you ever left the dog alone in the car? Yes No How did he/she react?Does your dog react to loud noises? Yes No Please describe
