Behavior History Form


What brand of food do you feed?

Name any and all collars/harnesses/leashes you have used.


Do you feel they have been effective in controlling your dog?


What equipment have you used in the past?


Has your dog ever bitten anyone?

Who and where did the dog bite? Describe the circumstances.

How were you referred?

Veterinarian Information:

Date of last Vet Visit

Behavior Triggers:

Description of Problems/Incidents

What have you done to stop the behavior?

Over time has the behaviour gotten

Describe your goals for your dog

You may be asked to change routine care and procedures such as exercise and interaction with your dog and to work Behavior Modification procedures into your daily activities. Are you willing and able to do this along with dedicating at least 15 minutes of rote training for basic commands daily?

The following questions are for past history. Do not attempt to try them at this time. Please mark the appropriate box if your dog has exhibted any of the listed behaviors in the past at any time when you or any memberof the family has done the following:

Touch dog's food or add food while eating

Walk past dog while eating

Take away real bone, rawhide or delicious food

Walk by dog when the dog has a real bone, rawhide, or delicious food

Touch delicious food when dog is eating

Take away a stolen object

Physically wake dog up or disturb resting dog

Restrain dog when it wants to go someplace

Lift dog

Pet dog

Medicate dog

Handle dog's face/mouth

Handle dog's feet

Trim the dog's toenails

Groom Dog

Bathe or towel off

Take off or put on collar

Hold dog by the muzzle

Stare at the dog

Reprimand dog in a loud voice

Visually threaten dog with newspaper, hand, etc.

Hit the dog

Walk by dog in crate

Walk by talk to dog on furniture

Physically remove dog from furniture

Make dog respond to command


Did you acquire your dog after 3 months of age?

Did you acquire your dog at 5 weeks or less?
Was your dog acquired from a shelter or pound?

Has your dog had multiple owners during his/her life?

Was your dog acquired from a pet shop?

Was your puppy an orphan or hand raised?

Was your dog the single puppy in a liter?


Does your dog follow you around the house?

Does your dog become anxious at the sound of car keys?

Is your dog anxious when you put on coat or shoes?

Does your dog become aggressive when you leave?

Does your dog exhibit other problem behaviors as you prepare to leave?

Does your dog bark or whine excessively within 30 minutes of your departure?

After you leave does your dog's activity level decrease?

After you leave does your dog appear depressed?

After you leave does your dog have a loss of appetite?

Only in your absence does your dog destroy property?

Only in your absence does your dog urinate or defecate in your home?

Does your dog regularly have diarrhea, vomit, or lick excessively in your absence?

Does your dog exhibit an excessive greeting on your return (jumping, hyperactivity, barking, more than 2 or 3 minutes?