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Initial Dog Behavior History Form (MVA/MVUCS)

Please complete the form below prior to your appointment. If you have any questions please email us at info@staging.metro-vet.designscreatifs.com.

"*" indicates required fields

X/Twitter

This field is for validation purposes and should be left unchanged.

General Information

Name*

First Last

Date of Appointment*

MM slash DD slash YYYY

Who referred you?*

Basic Pet Information

Dog's Name*

Current Age (indicate months or years)*

Breed*

Sex*

Spay or Neutered?*

Yes

No

Date When Acquired*

MM slash DD slash YYYY

Source

Breeder

Shelter/Rescue

Stray

Other

Did you meet your dog's parents?*

Neither

Mother only

Father only

Both Mother and Father

History Prior to Acquisition (if known)

Household Information

Household Members (including you)*

Name

Age

Relationship to you

Occupation

Relationship with pet (e.g., follows, trains, no interaction, etc.)

Is anyone in the household pregnant or planning to adopt or foster a child in the near future? (This is asked for safety reasons. You are not obligated to answer.)

Yes

No

Please provide a due date if applicable or any relevant information

Have you had dogs as an adult before?

Yes

No

Household Pets (aside from dog presenting for evaluation)

Name

Species

Age, breed, sex, neuter status

Interactions with patient

What type of area do you live in?*

Other type of area:*

What type of home do you reside in?*

Other home type*

Do you have a yard?*

Yes

No

Do you have a fence?*

Yes

No

What type?*

Are you planning on moving within the next few months?*

Yes

No

When and where?*

Have there been any changes in your household since acquiring your dog (e.g. new job, move)?*

Yes

No

Explain:*

Aggression (if applicable)

Only fill out information about triggers that apply to your dog; otherwise leave the field blank.

For any trigger applicable to your dog, please describe specific incidents of aggression including:

your pet’s age when it was first observed and at the time of incident(s)
targets of the aggression
location
how you responded
frequency of incidents
body language (growling, barking, lunging, biting)
any other relevant information

People living in the home

Other pets in the home

Guests

Unfamiliar people passing or approaching the home/yard

Stimuli (dogs, strangers, cars, etc.) on walks

Unfamiliar dogs when off leash

Veterinary clinic

Other triggers of aggression not listed above

Bite History (if applicable)

Has your dog made contact with an individual during the aggression?

Yes

No

What type of injury?

Scratch

Bruise

Puncture(s)

Tear

How many times has your dog bitten a person?

How many times has your dog bitten a dog/other animal?

How many times did a bite break skin with a person?

How many times did a bite break skin with an animal?

If your dog has a bite history, was any incident reported to Animal Control or other authorities?

Yes

No

To whom?

Is there any legal action pending because of this pet?

Yes

No

Which incident(s)?*

If not already described, please explain the bite incidents.

Anxiety Screen

What is your dog’s response to changes in the environment or subtle, sudden noises?*

Does your dog have any difficulty settling within the home?*

Does your dog do any of the following more than you would expect?

Lip licks or yawn

Lick or chew their body

Lick objects

Lick people

Does your dog display any reaction to noises such as thunderstorms, fireworks, or other loud noises?*

Yes

No

Explain:*

Does your dog do any of the following?

Chase his/her tail

Chase lights/shadows

Snap at the air

Other fears or anxieties not already describe:

Describe your dog’s behavior at the veterinary clinic, if not already described:

Does your dog show signs of stress while you are gone and if so, which ones?*

No

Urination

Defecation

Hypersalivation

Destructive behavior

Vocalization

Other

Other signs:*

On average, how long is your pet home alone?*

How do you prepare to leave your dog home alone?*

Other Behavior Concerns

Describe any other behaviors you find concerning that you have not yet mentioned.

Daily Activities

Is your dog walked daily?*

Yes

No

How often and for how long?*

What other type of exercise does your dog receive?

Fetch

Run

Agility

Other

Other types of exercise:*

Is your dog playful?*

Yes

No

Explain:*

What kinds of toys does he/she like?*

Is your dog ever confined?*

Yes

No

During what situations is your dog confined?*

With which method is your dog confined?*

What is their response?*

If crated, what type of crate?

Where is the crate located? (if applicable)

How do you get your dog inside? (if applicable)

What does your dog have access to inside? (if applicable)

Does your dog choose to spend time inside of it? (if applicable)

Training and Obedience

Has your dog ever attended group training classes?*

Yes

No

Companies/Trainers:

Age of Dog (at the time):

Have you ever hired a private trainer?*

Yes

No

Companies/Trainers:

Age of Dog (at the time):

What cues does your dog perform regularly and reliably?

Sit

Down

Come

Place

Look

Touch

Other

How do you correct your dog when he/she misbehaves?*

What types of training aides do you currently use?*

What types of training aides have you previously used?*

Medical History

Primary Care Veterinarian Clinic*

Veterinarian's Name*

Date of Last Veterinary Visit

MM slash DD slash YYYY

Estimated Weight (indicate pounds or kilograms)*

Has your dog had baseline blood work (CBC, chemistry) performed within the past year?*

Yes

No

Date of last blood work*

MM slash DD slash YYYY

Please list your pet’s current medications, supplements, or other treatments below

Name of heartworm preventative

Name of flea/tick preventative

Medications

Name

Dose (in mg)

Frequency (e.g., once daily, as needed)

Has your dog previously been prescribed medications, supplements, or pheromones for his/her behavior that are not listed above?*

Yes

No

Please list the name, date started, date discontinued, dose, and effects.*

Any chronic medical conditions?*

Yes

No

Explain:*

Any current or history of pain (limping, difficulty getting up or lying down, resistance using stairs, slowing down on walks)?*

Yes

No

Explain:*

Have you noticed your pet exhibiting any of the following in the last 3 months?

Itching

Vomiting

Diarrhea

Other

What else?*

Does your pet have a history of seizures?*

Yes

No

Current Diet Brand*

Amount and Frequency*

How would you describe your dog's appetite?*

Excessive

Good/Average

Poor

Explain:

Does your dog have any confirmed or suspected food allergies or sensitivities?*

Yes

No

Note: We will offer treats during the appointment based on this answer.

Explain:

Future Considerations

What are your goals for treatment?*

Have you considered rehoming or behavioral euthanasia for your dog?*

Please tell us about your favorite qualities and interactions that you have with your dog!*

In An Emergency

Phone MVA: 610-666-1050
Phone MVUCS: 610-61MVUCS
Phone Hickory: 610-880-3534

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