Veterinary Behavior Solutions

Dr. Lynn R. Honeckman

Phone: 321-332-2153

Fax: 407-438-7487

Behavior Consultation Questionnaire

General Client Information

Date:

Client’s Name:

Home Address:

Phone: (Cell) ( Work) (Home)

E-mail:

Veterinarian’s Name and Animal Hospital:

How did you hear about Veterinary Behavior Solutions?

Pet Information

Pet’s Name:

Breed of Dog or Cat: Color/Description

Age of Pet: Date of Birth:

Sex of Pet: Spayed or Neutered? ____ yes ____no

If yes, at what age? __________

Where did you obtain this pet? ____________________________________________________

How old was your pet when you first acquired it? ____________________________________

How long have you had this pet? __________________________________________________

Has this pet had other owners? ___________________________________________________

Describe your pet’s personality: ___________________________________________________

What do you like most about your pet? _____________________________________________

The Household Environment

What kind of home do you have?

____apartment ____townhouse/condo ____house

List each family member living in your home (include sex and age)

1. _______________________________________________

2. _______________________________________________

3. _______________________________________________

4. _______________________________________________

5. _______________________________________________

List all other pets in the home (include species, breed, age, and sex)

1. _______________________________________________

2. _______________________________________________

3. _______________________________________________

4. _______________________________________________

5. _______________________________________________

Where does your pet sleep?

During the day? _____________________________

At night? _____________________________

Have there been any recent changes to your household? (New baby? College Student Leaving?)

_________________________________________________________________________________________

_________________________________________________________________________________________

Daily Routine

What percentage of the day does your pet spend inside? _____

What percentage of the day does your pet spend outside?_____

How many times is your pet walked or let out per day? _____

If your pet is walked, what is the average length of the walk?________________________________

What type of exercise/play does your pet receive? _____________________________________________

How often? How long? _____________________________________________

What are your pet’s favorite toys? ______________________________________________________________

Favorite games? _______________________________________________________________

Is your pet crate-trained? _____

How much time does your pet spend in the crate each day? ___________________________

Please describe the family’s daily routine: ______________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Training History

Has your pet received Obedience training? _____

Where? When? _____________________________________

_______________________________________________________

What type of training collar have you used? _____________________________________

Briefly describe the training techniques: _____________________________________

_________________________________________________________________________

_________________________________________________________________________

What commands does your pet know? _____________________________________

_________________________________________________________________________

Does your pet know any tricks? ___________________________________________

_________________________________________________________________________

Diet History

What do you feed your pet? (Specific Type/brand) ________________________________

How many meals does your pet eat each day? ________________________________

How much do you feed at each meal? ________________________________

How often do you give treats? ________________________________

What types? (Be specific) ________________________________

How often does your pet receive human food each day? __________________________

What is your pet’s favorite food reward? __________________________

__________________________________________________________________________

Housetraining

For Dogs: At what age was your dog completely housebroken? __________________________

Does your pet ever have accidents in the house? __________________

_____ urination _____ defecation

Where does your pet eliminate outside? ____________________________________

For Cats: How many litterboxes do you have? _________

Describe the types of litterboxes: (Be specific) __________________________

_____________________________________________________________________

_____________________________________________________________________

What type of litter do you use? ________________________________________

Where are the litterboxes located? ________________________________________

_____________________________________________________________________

_____________________________________________________________________

Medical History

Dates of most recent vaccinations:

Dogs: Rabies__________ Cats: Rabies__________

DHLPP__________ FVRCP__________

Bordetella__________ FELV____________

FELV/FIV blood test______________

____Neg ____Pos

Is your cat declawed? ___________

Front paws? ___________

Rear paws? ___________

Age at time of declaw? ___________

Is your pet currently receiving heartworm prevention? _____

Is your pet currently receiving flea prevention? _____

Does your pet have any Current Medical Problems? _______________________________________

Is your pet currently taking any other medications (drug name and dose)? ______________________________

Primary Behavioral Complaint

What is the reason for this consult? _____________________________________

_________________________________________________________________________

_________________________________________________________________________

When did the problem begin? ___________________________________________

What has been attempted already to solve this problem? _________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Has the problem improved,stayed the same, or worsened? _________________________

Describe the problem in detail: ___________________________________________

Please describe any factors not covered in this form that you think may be important for understanding and treating your pet.