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).
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Owner Information
Name
Address
Home Phone
Work Phone
Cell Phone
Email
Best method to contact
3
Patient Information
Name
Age
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
Yes
No
Spayed or Neutered?
Please Select
Please Select
Canine
Feline
Species
Breed
4
Medical History
When was the last physical examination performed on your pet?
Please Select
Please Select
Yes
No
Have there been any medical tests performed associated with the behavioral problem?
5
Please obtain a copy of all medical tests performed and submit with this form.
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At what age?
Reason for procedure? routine/attempt to modify behavior/other
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Are you planning on breeding your pet?
Yes
No
8
Please Select
Please Select
Yes
No
Are vaccinations, including rabies vaccination, current?
Please Select
Please Select
Yes
No
Does your pet have any preexisting or current medical problems?
List any medications that your pet has received in the past month or is currently taking
List any medications, including homeopathic remedies, that your pet has ever received for the treatment of a behavioral problem
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Please list
10
Has your pet ever had a seizure?
Yes
No
11
Household InformationPlease list all members of your household, include ages of children and hours away from home.
Name
Gender
Age
Relationship (self, husband, wife, etc.)
Hours away/day
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2
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5
Name
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Gender
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Age
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Relationship (self, husband, wife, etc.)
Row 0, Column 3
Hours away/day
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Name
Row 1, Column 0
Gender
Row 1, Column 1
Age
Row 1, Column 2
Relationship (self, husband, wife, etc.)
Row 1, Column 3
Hours away/day
Row 1, Column 4
Name
Row 2, Column 0
Gender
Row 2, Column 1
Age
Row 2, Column 2
Relationship (self, husband, wife, etc.)
Row 2, Column 3
Hours away/day
Row 2, Column 4
Name
Row 3, Column 0
Gender
Row 3, Column 1
Age
Row 3, Column 2
Relationship (self, husband, wife, etc.)
Row 3, Column 3
Hours away/day
Row 3, Column 4
Name
Row 4, Column 0
Gender
Row 4, Column 1
Age
Row 4, Column 2
Relationship (self, husband, wife, etc.)
Row 4, Column 3
Hours away/day
Row 4, Column 4
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Please list all household pets, including the patient, in the order acquired
Name
Species
Breed
Gender
Age
Age acquired
1
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2
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3
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4
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5
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1
2
3
4
5
Name
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Species
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Breed
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Gender
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Age
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Age acquired
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Name
Row 1, Column 0
Species
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Breed
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Gender
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Age
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Age acquired
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Name
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Species
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Breed
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Gender
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Age
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Age acquired
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Name
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Species
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Breed
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Gender
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Age
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Age acquired
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Name
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Species
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Breed
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Gender
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Age
Row 4, Column 4
Age acquired
Row 4, Column 5
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Background Information
How old was your pet when you first acquired him/her?
Please Select
Please Select
stray/found
professional breeder
hobby breeder
humane shelter/SPCA
breed rescue group
newspaper adoption (not breeder)
pet store
friend
other
Where did you acquire this pet from?
If other (please explain)
Please Select
Please Select
family pet
working dog (hunting)
protection/guard dog
for breeding
Why did you get this pet?
Please Select
Please Select
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
Is your pet (please check all that apply)
Please Select
Please Select
friendly
shy
outgoing
fearful
aggressive
playful
other
Describe your pet as a puppy/kitten
If other (please explain)
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How many times is your pet walked per day?
If your pet is walked, what is the average length of time for each walk(in minutes)?
Who walks your pet?
What type of collar/leash do you use to walk your pet?
15
Please Select
Please Select
0–25%
25–50%
50–75%
75–100%
What percentage of the day does your pet spend inside?
Please Select
Please Select
dogs
cats
other
none
Have you had pets before?
Please Select
Please Select
apartment
townhouse/condominium
house with small yard
house with large yard
farm/rural property
What kind of living situation do you have?
Please Select
Please Select
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
Is your pet allowed on furniture?
Please Select
Please Select
free choice (bowl is kept full of food)
one meal per day
two meals per day
more than two meals per day
Is your pet fed
Please Select
Please Select
Yes
No
Is your pet fed treats on a daily basis?
Please Select
Please Select
free in house
outside house
in crate
restricted to certain areas in house
Where is your pet when left home alone?
If outside house (Describe)
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Do you play with your pet routinely?
Yes
No
17
If yes, describe a typical play episode
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Describe how you prepare to leave the house when the pet will be left alone. Do you ignore your pet, put it in a crate, say goodbye to pet, etc.?
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For Dogs Only
Please Select
Please Select
no school, trained yourself
puppy kindergarten
group lessons, basic
group lessons, advanced
private trainer at house
private trainer, sent to trainer
What is your dog’s obedience school history?
Please Select
Please Select
Yes
No
Is your dog trained to go to a certain spot/location (e.g., bed, crate, mat) on a verbal command?
Please Select
Please Select
Perfect
Good
Moderate
Poor
If yes, how reliable is the response?
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What commands does your dog know and how well (circle)?
Perfect
Usually
Needs work
Sit
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Stay
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Lie down
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Come
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Heel
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Fetch
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Drop it
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Watch me
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Row 7, Column 2
Sit
Stay
Lie down
Come
Heel
Fetch
Drop it
Watch me
Perfect
Row 0, Column 0
Usually
Row 0, Column 1
Needs work
Row 0, Column 2
Perfect
Row 1, Column 0
Usually
Row 1, Column 1
Needs work
Row 1, Column 2
Perfect
Row 2, Column 0
Usually
Row 2, Column 1
Needs work
Row 2, Column 2
Perfect
Row 3, Column 0
Usually
Row 3, Column 1
Needs work
Row 3, Column 2
Perfect
Row 4, Column 0
Usually
Row 4, Column 1
Needs work
Row 4, Column 2
Perfect
Row 5, Column 0
Usually
Row 5, Column 1
Needs work
Row 5, Column 2
Perfect
Row 6, Column 0
Usually
Row 6, Column 1
Needs work
Row 6, Column 2
Perfect
Row 7, Column 0
Usually
Row 7, Column 1
Needs work
Row 7, Column 2
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For Cats Only
Please Select
Please Select
0
1
2
3
4
>4
How many litter boxes do you have?
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Describe the litter boxes (check all that apply and put in parentheses the number of boxes for which the description is true)
Number
open
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covered
Row 1, Column 0
large
Row 2, Column 0
small
Row 3, Column 0
liner
Row 4, Column 0
no liner
Row 5, Column 0
open
covered
large
small
liner
no liner
Number
Row 0, Column 0
Number
Row 1, Column 0
Number
Row 2, Column 0
Number
Row 3, Column 0
Number
Row 4, Column 0
Number
Row 5, Column 0
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clumping litter
plain clay
scented
unscented
playground sand
large pellets
wheat litter
cedar chips
varies with each purchase
other
What kind of litter do you put in the boxes (check all that apply)?
If other, please specify
closet
kitchen
bathroom
bedroom
attic
laundry room
living room
basement
stairwell
other
Where are the litter box(es) located(check all that apply)?
If other, please specify
Please Select
Please Select
no
yes, front declawed only
yes, back and front feet
declawed
Is your cat declawed?
Please Select
Please Select
Yes
No
Does your cat use a scratching post?
Please Select
Please Select
Yes
No
Does your cat have any outdoor access?
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Reaction to handling by family membersDoes 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).
Adult owner (female)
Adult owner (male)
Children
Any specific individual
Handling/grooming
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Petting or hugging
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Disturbed when resting
Row 2, Column 0
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Row 2, Column 2
Row 2, Column 3
Disciplining
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Row 3, Column 2
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Walking on the lead
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Taking food away
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Taking other objects
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Handling/grooming
Petting or hugging
Disturbed when resting
Disciplining
Walking on the lead
Taking food away
Taking other objects
Adult owner (female)
Row 0, Column 0
Adult owner (male)
Row 0, Column 1
Children
Row 0, Column 2
Any specific individual
Row 0, Column 3
Adult owner (female)
Row 1, Column 0
Adult owner (male)
Row 1, Column 1
Children
Row 1, Column 2
Any specific individual
Row 1, Column 3
Adult owner (female)
Row 2, Column 0
Adult owner (male)
Row 2, Column 1
Children
Row 2, Column 2
Any specific individual
Row 2, Column 3
Adult owner (female)
Row 3, Column 0
Adult owner (male)
Row 3, Column 1
Children
Row 3, Column 2
Any specific individual
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Adult owner (female)
Row 4, Column 0
Adult owner (male)
Row 4, Column 1
Children
Row 4, Column 2
Any specific individual
Row 4, Column 3
Adult owner (female)
Row 5, Column 0
Adult owner (male)
Row 5, Column 1
Children
Row 5, Column 2
Any specific individual
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Adult owner (female)
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Adult owner (male)
Row 6, Column 1
Children
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Any specific individual
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Behavioral ProblemPlease 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?
Behavior Problem
Very serious
Serious
Not serious
1
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2
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1
2
3
4
Behavior Problem
Row 0, Column 0
Very serious
Row 0, Column 1
Serious
Row 0, Column 2
Not serious
Row 0, Column 3
Behavior Problem
Row 1, Column 0
Very serious
Row 1, Column 1
Serious
Row 1, Column 2
Not serious
Row 1, Column 3
Behavior Problem
Row 2, Column 0
Very serious
Row 2, Column 1
Serious
Row 2, Column 2
Not serious
Row 2, Column 3
Behavior Problem
Row 3, Column 0
Very serious
Row 3, Column 1
Serious
Row 3, Column 2
Not serious
Row 3, Column 3
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Describe a typical episode of the behavioral problem(s)
27
The behavior occurs
times
Please Select
Please Select
Day
Week
Month
per day / week / month
Describe the first incident (including date)
Describe the most recent episode (including date)
28
Has the frequency of the behavior increased / decreased / remained unchanged?
Has the intensity of the problem increased / decreased / remained unchanged?
Have there been any changes in the household (new pet, new family member,schedule change, etc.)?
If so, describe
29
What have your tried to do to change the problem behavior? Please list all things you have tried whether they have been useful or not
30
Please Select
Please Select
Yes
No
Have you considered finding another home for your pet?
Please Select
Please Select
Yes
No
Have you considered euthanasia (putting your pet to sleep)?
Is there any other information you would like to add?
Should be Empty: