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.

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)
Please feel free to upload a picture of your pet for our medical records.

Cancelof
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 using one line for each animal by clicking 'Add Row'. Please describe your dog's relationship to the other animals (e.g., friendly, hostile, or fearful).
Are any of the animals kept apart or managed separately due to aggression?

Behavior Problem(s)
What is the main behavior problem(s) or complaint? How frequently does the main problem (or problems) occur (how many times daily, weekly, or monthly)?*
Additional problem(s) - please list below:
Progression of Behavior Problem
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.
Seriousness #

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
Cornell University Hospital for Animals is part of the College of Veterinary Medicine. We’re here to give animals excellent care, help train future veterinarians, and learn more about diseases and how to treat them.

As part of our training program, we use closed-circuit cameras in select exam rooms for observation. We may also use artificial intelligence to help write your pet’s medical record based on an audio recording of your visit. These tools help us work more efficiently and care for more pets. Your doctor may take pictures or video of your pet’s behavior to include in their medical record. We also save any pictures or videos you share with us during your visit.

To help train veterinary students, we may use photos or videos from your visit for teaching purposes at Cornell. This is a routine part of our program and cannot be opted out of. However, please let us know if you’re comfortable with us using these materials for teaching outside Cornell or on social media.
Use of Recorded Material

Yes, I allow the use of photos or videos for teaching outside Cornell, including social media.Yes, I allow the use of photos or videos for teaching outside Cornell, but not on social media.No, I do not allow the use of photos or videos for teaching outside Cornell or social media.
Terms of Service
We want to make sure you understand the cost of care and our payment policies clearly—both before treatment begins and throughout your pet’s care. If you have questions at any time, please ask.

Initial Behavior Consultation

The first consultation lasts about 90 minutes and takes place in person at Cornell University Hospital for Animals, 930 Campus Road, Ithaca, NY.

During this visit, we will:

• Review your pet’s medical and behavior history
• Assess any safety risks
• Perform a physical exam—as much as your pet allows without added stress
• Talk through the diagnosis, expected outcome, and treatment options
• Give you an action plan with safety tips, tools, and educational materials
• Discuss and prescribe medications or supplements if needed
• We’ll also schedule a 30-minute follow-up appointment, usually done by Zoom 8–12 weeks later.

All consultations are private and confidential. A written report will be sent to you, your regular veterinarian, and your trainer (if requested) within 2-3 days.

Follow-Up Support

Because we receive many requests and replying takes time, we can only offer limited email support for 3–4 months after your consultation. If you have concerns about medications or serious behavior problems, please reach out. For other questions, a follow-up appointment with the doctor may be needed.

Behavior Progress Exams

• These are scheduled as needed for your pet and last 30–60 minutes, either in person or by Zoom.
• We must see your pet in person every 9–12 months to continue recommending treatment or prescribing medication.
• If new problems come up or your pet isn’t improving, earlier follow-ups may be needed.
• To give your pet the best care, we recommend scheduling a follow-up appointment before making any major changes to their treatment plan— especially if we haven’t seen them in person in over three months.
• You are responsible for scheduling all follow-up appointments—please plan ahead.

Pricing and Payment

• Please call or email us for current pricing.
• The initial consultation includes a 30-minute remote follow-up at no extra charge.
• Any tests, tools, medications, supplements, or extra training sessions will be in addition to the initial consultation fee.
• We spend a lot of time getting ready for each appointment by reviewing your pet’s history form and medical records. If you don’t confirm your appointment at least 7 days in advance, it may be cancelled.
• Payment is due at the time of service.
• Prices may change without notice.

Important Notes About Treatment and Safety

• Behavioral treatment and medication may help, but results are not guaranteed.
• Behavior problems can be complex and caused by many factors.
• Success depends on your commitment to the treatment plan and giving medications correctly.
• We will do our best to avoid side effects, but some reactions may be unpredictable.
• If your pet shows aggressive behavior, you are responsible for keeping other people and animals safe around your pet. Getting advice from a veterinarian does not transfer liability. Even if your pet’s aggression improves with treatment, there is no guarantee it won’t happen again.
• By agreeing below, you understand that it is your responsibility to keep other people, children, and animals safe around your pet.
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)

Progression of Behavior Problem

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