You can always press Enter⏎ to continue
AMC Chicago- Behavior History Form
  • 1

    Please fill out this Behavior History Questionnaire so that we can better understand your pet’s behavior problem(s).

    Press
    Enter
  • 2
    Press
    Enter
  • 3
    • Male
    • Female
    • Yes
    • No
    • Canine
    • Feline
    Press
    Enter
  • 4
    • Yes
    • No
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    • Yes
    • No
    Press
    Enter
  • 8
    • Yes
    • No
    • Yes
    • No
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Press
    Enter
  • 11
    Please list all members of your household, include ages of children and hours away from home.
    1 of 5
    Press
    Enter
  • 12
    Please list all household pets, including the patient, in the order acquired
    1 of 5
    Press
    Enter
  • 13
    • stray/found
    • professional breeder
    • hobby breeder
    • humane shelter/SPCA
    • breed rescue group
    • newspaper adoption (not breeder)
    • pet store
    • friend
    • other
    • family pet
    • working dog (hunting)
    • protection/guard dog
    • for breeding
    • allowed to run free, unsupervised when outside
    • always enclosed in a contained area when not on leash
    • leash-walked
    • outside, unleashed but supervised
    • outdoors only
    • friendly
    • shy
    • outgoing
    • fearful
    • aggressive
    • playful
    • other
    Press
    Enter
  • 14
    Press
    Enter
  • 15
    • 0–25%
    • 25–50%
    • 50–75%
    • 75–100%
    • dogs
    • cats
    • other
    • none
    • apartment
    • townhouse/condominium
    • house with small yard
    • house with large yard
    • farm/rural property
    • yes, all furniture
    • yes, only specific pieces
    • yes, only if invited
    • no, but gets on anyway in presence and absence of people
    • no, but gets on furniture in absence of people
    • no, to my knowledge never gets on furniture
    • free choice (bowl is kept full of food)
    • one meal per day
    • two meals per day
    • more than two meals per day
    • Yes
    • No
    • free in house
    • outside house
    • in crate
    • restricted to certain areas in house
    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Press
    Enter
  • 18
    Press
    Enter
  • 19
    • no school, trained yourself
    • puppy kindergarten
    • group lessons, basic
    • group lessons, advanced
    • private trainer at house
    • private trainer, sent to trainer
    • Yes
    • No
    • Perfect
    • Good
    • Moderate
    • Poor
    Press
    Enter
  • 20
    1 of 8
    Press
    Enter
  • 21
    • 0
    • 1
    • 2
    • 3
    • 4
    • >4
    Press
    Enter
  • 22
    Describe the litter boxes (check all that apply and put in parentheses the number of boxes for which the description is true)
    1 of 6
    Press
    Enter
  • 23
    • clumping litter
    • plain clay
    • scented
    • unscented
    • playground sand
    • large pellets
    • wheat litter
    • cedar chips
    • varies with each purchase
    • other
    • closet
    • kitchen
    • bathroom
    • bedroom
    • attic
    • laundry room
    • living room
    • basement
    • stairwell
    • other
    • no
    • yes, front declawed only
    • yes, back and front feet
    • declawed
    • Yes
    • No
    • Yes
    • No
    Press
    Enter
  • 24
    Does your pet show aggression in the following circumstances? This can include growling, hissing, snarling (showing teeth), lunging, nipping, snapping, or biting.Please fill in the chart: (Y = Yes, N = No, N/A = doesn’t apply). If biting has occurred in any of these circumstances, please describe the wound (tear, puncture, bruising).
    1 of 7
    Press
    Enter
  • 25
    Please use the chart below to list the behavioral problem(s) that you wish to address,and how much of a problem do you consider the behavior to be?
    1 of 4
    Press
    Enter
  • 26
    Press
    Enter
  • 27
    • Day
    • Week
    • Month
    Press
    Enter
  • 28
    Press
    Enter
  • 29
    Press
    Enter
  • 30
    • Yes
    • No
    • Yes
    • No
    Press
    Enter
  • Should be Empty:
Question Label
1 of 30See AllGo Back
close