Contact Information
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| Name of Owner:
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| Daytime Phone:
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| Evening Phone:
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| Email address:
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| Address:
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Name and Phone Number
of your regular veterinarian:
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| How were you referred to Animal Behavior Insights?:
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Basic History
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| Name of Pet, Age, Sex and Weight in lbs:
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| Has your pet been neutered or spayed? If so, please give date.:
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| Where did you acquire your pet? How old was he/she at that time?:
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| Has a recent physical exam been performed by a veterinarian? Did this include any medical tests?:
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The Nature of the Problem
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| Please describe the main behavioral issue(s) you are seeking help for with your pet.:
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When did this behavior begin?
Has it gotten worse or better?:
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| How often does this behavior occur? What situations prompt it?:
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What other behavioral issues does your pet display?
(Please include all behaviors, even if they don’t currently bother you or you don’t feel they relate to the main issue.) |
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| Secondary Issue A, frequency and situations that prompt it:
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| Secondary Issue B, frequency and situations that prompt it:
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| Secondary Issue C, frequency and situations that prompt it:
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| What strategies have you already tried to change your pet’s inappropriate behavior?:
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| What is your pet’s training history? Please include any commands/tricks your pet knows and any classes attended with your pet.:
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| What do you feed your pet? Please list brand and amount and how often they are fed. :
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| Please list the human members of the household, names and ages if under 18.:
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| Please list other animal members of the household, Name, Species, Age, Sex and Neutered/Spayed status. :
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| Where does your pet stay when you are gone?:
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| Where does your pet sleep at night? :
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| What exercise does your pet receive and how often? (Think about walks, playtime, games etc.) :
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| Please give a brief health history including current medications w/doses, current conditions and any major illnesses or injuries sustained earlier in life. :
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How do you perceive the severity
of this problem?:
| This problem is interesting to me and I want to find out more about it from a curiosity standpoint.
This problem is not a big problem, but I would like to see if it can improve.
This problem is a big problem for our family, but if it doesn't improve I will still keep the pet.
This problem is very serious, and if I can't find a solution I am considering rehoming or euthanizing the pet.
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