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College of Veterinary Medicine

Canine Behavioral History Form

Owner Information

Name
How do you prefer to be addressed?

Spouse/Partner Name
Home address
Primary phone type
Secondary phone type

Pet Information

Sex
Spayed/Neutered
Where did you obtain this dog?

Use of pet

Veterinary Information

Your pet’s primary veterinarian’s name
Note: After any behavioral consultation, we will send a referral summary to your pet’s primary veterinarian.
Clinic or hospital address

Principal Behavioral Complaint

How would you describe the severity of the main problem?
Have you considered euthanasia?

For each problem, please fill requested details below.

(At the initial consult, we will focus on no more than three of the most important problems to you. The rest will be addressed in future appointments as needed.)
Problem 1
Please indicate the number of times the main problem has occurred in each of the times indicated.
Problem 2
Please indicate the number of times the main problem has occurred in each of the times indicated.
Problem 3
Please indicate the number of times the main problem has occurred in each of the times indicated.

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