• 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

  • Your preferred pronouns (this helps us understand the best way to address you):
  • Format: (000) 000-0000.
  • Primary Phone Type:*
  • Format: (000) 000-0000.
  • Alternate Phone Type:

  • Referral Information

  • Who referred you to us?*

  • Pet Information

  • Sex*
  • Date of Birth*
     - -
  • Date
     - -
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  • Primary Care Veterinarian Information

  • Trainer Information

  • Are you currently working with a trainer or behavior consultant?
  • Format: (000) 000-0000.
  • Would you like us to share our report with your trainer and communicate with them about your pet's diagnosis and treatment plan?

  • Household Information

  • Please list all the people (including yourself) living in your household and the ages of the children.

    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?

  • Behavior Problem(s)

  • Progression of Behavior Problem

  • Describe several examples in detail:

  • Seriousness

  • How serious is the problem? Check the most appropriate response.*

  • Aggression Toward People

  • Is aggression towards people a concern?
  • Rows

  • Please answer Yes or No to these characteristics of your dog’s aggressive behavior:

  • Attacks are sudden and surprising:
  • Episodes appear unprovoked:
  • My dog is abruptly docile after an episode:
  • My dog appears “sorry” afterward:
  • My dog appears disoriented afterward:
  • Episodes are associated with a “glazed” or “absent” expression:
  • I can usually tell what will set my dog off:
  • The aggressive behavior is new and uncharacteristic:
  • Has your dog bitten and broken skin?

  • Your Dog's Background

  • Where did you get your dog from?
  • Have you owned dogs before?
  • Was a temperament test performed?
  • Did you meet your dog’s parents? If yes, describe their behavior.
  • Do you have any information about your dogs littermates?

  • Diet and Feeding

  • How is your dog’s appetite?

  • Overall Health and Wellness

  • Does your dog currently exhibit or have a history of any of the following medical concerns? Check all that apply.
  • Has your dog had recent (within the last 3 months) veterinary exams or diagnostic tests? Check all that apply.
  • Date of last Rabies Vaccine?*
     - -
  • Is your dog on routine parasite, flea, tick or heartworm preventatives?*
  • How do you feel your dog did at the most recent veterinary visit? (please check one) FAS below stands for fear, anxiety, and stress. **See the chart below for more information.
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  • Medications, Preventatives, and Supplements

  • Has your dog ever been on medication for behavioral reasons in the past?

  • Environment and Management

  • Has anything changed recently in your household? Examples include moving, people moving in or out, renovations, a new baby, etc.
  • What type of household do you live in?

  • Training and Enrichment

  • What best describes your dog’s level of activity?
  • What type of collar/harness does your dog wear on walks, training, or when off leash?
  • What basic obedience has your dog had? (Select all that apply)
  • Indicate any behaviors your dog frequently performs:

  • 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

  • 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.

     

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  • Form Created 4/2024

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