Canine Behavior History Form

Canine Behavior History Form

Small Animal Community Practice, Behavior
Please answer the following questions and submit this form. Once we receive the completed form, we will contact you about scheduling.

This form is designed to be completed online only. Please read all questions carefully and answer them to the best of your abilities. Include all relevant information. Not every question may apply to every animal.

This form is very detailed and may take up to an hour or more to fill out, depending on the complexity of the problems.

You are allowed to save the form in draft and return to it later. A link to the email indicated under 'Owner Information' will be sent. Please note that the form will not allow you to submit unless all required fields are completed.

(*) Indicates required field.

Owner Information
Name:*

First NameLast Name
Your preferred pronouns (this helps us understand the best way to address you):

she/herhe/himthey/themOther
Email:*
If saving form to complete later, please make sure your email is correct in this field. Click Save at the bottom of the page.
Please list the full name(s) of any additional owners and preferred pronouns (the individuals in this field will be on the patient's file, which indicates that medical information can be shared and these individuals can make medical decisions.)
Primary Phone Number:*
Please enter a valid phone number.
Alterative Phone Number:
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Information
Who referred you to us?*

VeterinarianTrainerSelf-referralOther

Pet Information
Pet's Name*
Breed*
Color/Markings*
Sex*

FemaleFemale SpayedMaleMale Neutered
Weight (in lbs)*
Weight (in kg)
Calculated after entering weight in lbs
Date of Birth*

MonthDayYear
Check if this birth date is an estimate
Date

MonthDayYear
Date
Age Calculation (Years)
Primary Care Veterinarian Information
Veterinarian's Name:*
Clinic or Hospital Name:*
Clinic or Hospital Email:
example@example.com
Clinic or Hospital Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Trainer Information
Are you currently working with a trainer or behavior consultant?

YESNO
Trainer/Behavior Consultant Name:

First NameLast Name
Trainer/Behavior Consultant Email:
example@example.com
Trainer/Behavior Consultant Phone Number:
Please enter a valid phone number.
Would you like us to share our report with your trainer and communicate with them about your pet's diagnosis and treatment plan?

YESNO

Household Information
Please list all the people (including yourself) living in your household and the ages of the children (if under 18 years old).

Include each person’s attachment to the patient from 1-10 (with 1 being not attached and 10 very attached).
Do any children other than the ones listed above interact with your dog?

YESNO
If yes, please list the number of children and their ages. Briefly describe the relationship with the Patient (examples: the patient is scared of the child, they do not interact, patient loves them)
Please list all other animals in the household. Please describe your dog's relationship to the other animals (e.g., friendly, hostile, or fearful).
Are any of the dogs kept apart or are managed separately due to aggression?

Behavior Problem(s)
What is the main behavior problem(s) for complaint? How frequently does the main problem (or problems) occur (how many times daily, weekly, or monthly)? *
Additional problem(s) - please list below:
When did you first notice the main problem (how old was your dog)?
When did it first become a serious concern?
In what general circumstances does the problem behavior occur?
Has this problem changed in frequency? Please describe.
Has this problem changed in intensity? Please describe.
Has this problem otherwise changed?
Describe several examples in detail:
Most recent incident (include date):
Second to last incident (include date):
Third to last incident (include date):
Describe any other significant incidents:
What have you done so far to correct the problem?
How do you discipline your dog for this behavior and for any other misbehavior?
Seriousness
How serious is the problem? Check the most appropriate response.*

I am here only out of curiosity - problem is not serious.I would like to change the problem, but it is not serious.The problem is serious and I would like to change it, but if it remains unchanged that's all right.The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog.The problem is very serious and I would like to change it; if it remains unchanged I will have my dog euthanized or give him/her up.

Environment and Management
Who is the primary caretaker for your dog?
Has anything changed recently in your household? Examples include moving, people moving in or out, renovations, a new baby, etc.

YesNo
Please describe the change.
What type of household do you live in?

HouseApartmentFarm/ruralOther
What kind of access does your dog have to the outside (fenced-in yard, tied, leash walks)? Please describe.
Is your dog house-trained? If so, how was your dog house trained?
Does your dog ever urinate or defecate in the house? If so, please describe.
Where does your dog sleep at night?
Has your dog’s sleeping habits changed?
Where is your dog when they are alone in the house?
How many hours is your dog home alone on average (indicate weekdays versus weekends if they differ)?
Do you have a camera to see what your dog is doing when they are alone? If so, what kind?
Where is your dog when you have guests?
Does your dog tolerate being in a crate or other type of confinement?

Use of Recorded Material
The Cornell University Hospital for Animals is part of the College of Veterinary Medicine at Cornell. We are here to provide comprehensive and compassionate care to animals, provide an excellent learning experience for our veterinary students and to advance the understanding of disease and its treatment.

As part of the training program for our veterinary students, closed-circuit television cameras have been installed in each of the examination rooms. The doctor may also opt to record video or pictures of your pet's behaviors for our records. These will be stored on your pet's file for future review. This also includes any video or picture material you submit or share with us as part of the consultation.

Please indicate below if you allow us to use this material as part of educational teaching materials outside of Cornell or on social media (Facebook or others). 
Use of Recorded Material

Yes, I allow the use of video or pictures obtained or submitted for use in educational materials which may include social media.Yes, I allow the use of video or pictures obtained or submitted for use in educational materials but NOT on social media.No, I do not allow the use of video or pictures for use in educational materials or on social media.
Terms of Service
Our goal is to communicate the cost of care and payment policies as clearly and transparently as possible before starting and throughout treatment. We welcome any questions you have at any time.

Initial Behavior Consultation:

The initial behavior consultation is approximately 90 minutes, conducted in person at our Small Animal Community Practice, 968 Campus Road, Ithaca, New York. More details about the appointment are included below. At that time, we will also schedule a 30-minute follow-up appointment (typically conducted via Zoom 4-8 weeks after the initial appointment).
- We will review your pet’s medical and behavioral history and conduct a risk assessment.
- We will discuss the diagnosis, prognosis, and initial treatment options.
- You will be provided with an immediate action plan including safety and management protocols, tools, and educational materials specific to your pet’s needs.
- Medications and supplements will be discussed and prescribed if appropriate for your pet.
- A physical exam will be performed as much as your pet will allow without causing unnecessary stress.
All consultations are private and confidential. A written report will be provided to you, your primary care veterinarian, and your trainer (if requested) within 72 hours of your appointment.

Please understand that we are only able to offer reasonable email support for 3-4 months following your pet’s consultation. Do not hesitate to contact us with concerns about your pet’s medications or the progression of severe behavioral problems. Otherwise, all other problems will require follow-up with the doctor.

Behavior Progress Exams:
- Scheduled by request. These appointments are 30-60 minutes, either in-person or remote. Please be aware that we must see your pet in person every 6-12 months in order to recommend treatment and prescribe medication.
- If new behavioral problems arise, or your pet is not progressing as hoped, follow-ups might be needed sooner to effectively analyze your animal's condition and to continue offering advice. Note that we will not be able to advise on major changes in the treatment plan without seeing your pet.
- You are responsible for scheduling all follow-up appointments. Please plan accordingly.
Pricing:
- Initial Behavior Consultation for Dogs: $400
- Initial Behavior Consultation for Cats: $300
- Behavior Progress Exam: $150
- Behavior Progress Exam (Brief): $100
All initial consultations include a 30-minute remote follow-up appointment at no charge. All diagnostic tests, training tools, medications/supplements, and additional training and behavior modification sessions will be in addition to the consultation fee.

Payment Policy:
- Payment: Payment is due at the time of all services. We will contact you by phone after your remote appointment to arrange payment.
- Cancellation: We understand that schedules and circumstances change. We spend a significant amount of time in advance of your pet’s appointment reviewing the completed history form and medical records. We ask that you give us adequate notice (ideally 48 hours or more) if you decide to cancel your appointment.
- Prices are subject to change without notice.
By checking below, you understand that response to behavioral treatment or medical therapy cannot be guaranteed. Behavioral disorders can be very complicated and underlying causes are often multifactorial. The success of treatment depends on many factors, including your commitment to the behavioral modification plan as well as the correct administration of medications, if prescribed. Every effort will be made to anticipate and avoid an adverse reaction to treatment, but there may be unpredictable reactions or responses to treatment. If your pet is exhibiting aggressive behavior, liability for this behavior rests solely with you. Seeking and obtaining advice from a veterinarian does not transfer this liability. Furthermore, even if a pet’s aggression is diminished following treatment this does not ensure or imply that the aggressive behaviors will not occur again. By agreeing below you understand it is your responsibility to ensure the safety of other people, children, and animals that your pet may come in contact with.
We welcome any questions you have about our terms of service or pricing in the space below.
Form Created 4/2024
Should be Empty:

	Growl	Snarl/bare teeth	Snap/Bite	No Reaction	Not Applicable
Pet Dog
Hug dog
Kiss dog
Lift dog
Call off furniture
Push or pull off furniture
Approach when on furniture
Disturb while resting or sleeping
Approach while eating
Touch while eating
Take dog food away
Take human food away
Take water dish away
Take away rawhide
Take away biscuit or cookie
Take away real bone
Take away toy or object
Approach when dog has an object, toy, or bone
Verbally punish
Physically punish
Visual threat
Speak to dog (normal tone)
Stare at dog
Bend over dog
Push on dog’s shoulders or back
Approach dog when near spouse
Enter room
Leave room
Reach toward dog
Leash restraint
Collar restraint
Scruff restraint
Put leash on or take off
Put collar on or take off
Bathe dog
Towel dog
Groom or brush dog
Dog at groomer’s
Trim nails
Leash or collar correction
Response “sit” cue
Response “down” cue
Dog at veterinary clinic
Unfamiliar adult enters house or yard
Unfamiliar child enters house or yard
Familiar adult enters house or yard
Familiar child enters house or yard
Response to toddlers or babies
Dog in car at tollbooths or gas stations
Unfamiliar adult approaches owner, dog on leash
Unfamiliar child approaches owner, dog on leash
Dog in house, sees people outside
Response to other dogs while on leash
Response to other dogs while off leash

Canine Behavior History Form

Owner Information

Referral Information

Pet Information

Primary Care Veterinarian Information

Trainer Information

Household Information

Behavior Problem(s)

Seriousness

Aggression Toward People

Your Dog's Background

Diet and Feeding

Overall Health and Wellness

Medications, Preventatives, and Supplements

Environment and Management

Training and Enrichment

Use of Recorded Material

Terms of Service