Dog Behavior History Form

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Where did you obtain this dog?
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For what purpose was this dog obtained?
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Rate your experience with dogs
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PRINCIPAL COMPLAINT

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The severity is:
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How many times has the problem occurred
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The problems occur:
When the dog is left alone
In the presence of the family members
During the night when the family sleeps
When guest comes over
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Have you considered euthanasia?
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Behavior
Does this dog get along with other animals?
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Describe the dog's behavior:
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How does the dog react when frightened?
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Environment/Lifestyle:
Briefly describe home
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List each family member (including daily schedule, sex, and age if under 18):
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3.
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5.
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6.
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List other animals in the home 1:
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List other animals in the home 2:
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List other animals in the home 3:
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Diet:
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Describe feeding habits:
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Activity:
In what area of the house or yard is the dog when:
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Describe the dog’s grooming:
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Training:
What type of collar is used for walking/training?
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Has this dog had any formal obedience training?
Grade the success
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The dog’s ability to learn is
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Punishment
Have you used any of the correction techniques:
Physical (hitting)
Success
Noise (Shaker can/siren)
Success
Ultrasonic (Petagree)
Success
Water spray
Success
Verbal/shouting
Success
Time Out
Success
E-Collar
Success
Citronella collar
Success
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Success
Please indicate any other behavior problems:
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Please do not submit any Protected Health Information (PHI).

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