Behavior Evaluation Form Step 1 of 3 33% Today's Date* MM slash DD slash YYYY Owners NameEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneBusiness PhoneWho recommended you to us?GENERAL INFORMATIONPet's nameSpecies Dog Cat Other If otherAgeSex Male - Intact Male - Neutered Female - Intact Female - Spayed If spayed or neutered at what age?BreedColorWeight in lbs. Opt Out: Check this box if you do NOT want your pet’s picture or name displayed on our website, Facebook, Twitter, or any promotional materials. We love sharing our pictures with other pet lovers! At what age did you obtain the petWhere did you obtain this pet? friend, breeder, pet shop (name of store), humane society, otherFor what purpose was this pet obtained? Companionship, protection, breeding, show, otherWhere do you take your pet for regular veterinary care (if not us)?Time spent indoors (percent)Outdoors (percent)Is this pet left alone during the day?How long?In what area of the house or yard is the pet keptFamily homeFamily awayFamily asleepWhen guests visit Describe the pet's behaviorJust prior to your departureJust after your returnDiet% dryDry Brand% cannedCanned Brand% table scrapsFavorite treat(s)SupplementsWhen is the pet fed?By whom?Date of last physical examList all major surgical or medical problems and approximate datesList all medications (dosage, schedule & duration) that has been prescribed for a behavior problem and the resultsList all medications (including dosage and schedule) currently being taken by this petList the number of other pets in the homeCatsfemale intactfemale spayedmale intactmale neuterDogsfemale intactfemale spayedmale intactmale neuterOtherWhat is your pet’s relationship to the other animals (e.g. friendly, hostile, fearful)? Please describe.What toys/types of play does the pet enjoy?What amount of exercise or opportunity to exercise is given to the pet?Does he or she run free in the neighborhood?How often?Has this pet had any formal obedience training? Yes No Type Class Private instructor I trained my pet at home *If you selected "Private instructor", what is the name?What type of collar do you use for training? flat choke chain pinch/prong head halter Grade the success failed fair good excellent Please describe the type of discipline you use for general misbehaviorWhat will your pet do on command?Does this pet get along with other animals? If not, please explain.How does this pet react to unfamiliar people?What persons are in the pet's environment? Their schedules? Children’s ages? BEHAVIOR PROBLEM INFORMATIONPlease describe your pet's behavior problem(s):What month/year were the problem(s) first noted?When did it first become a serious concern?Where and under what circumstances was each problem(s) first noted?Describe the situation(s) in which the problem is most likely to occur?The problems occurwhen the pet is left alonealwaysusuallyrarelyneverin the presence of the family membersalwaysusuallyrarelyneverduring the night when the family sleepsalwaysusuallyrarelyneverFrequency of occurrenceHas there been a change in the frequency or intensity of the problem? Please describeWhat has been done so far to correct this problem?(discipline, confine, obedience training, etc.)What was the pet's response to the correction?Were there any significant changes in this pet's environment prior to the appearance of this problem? no moved or redecorated boarded visitors (human or pet) type of litter changed change in family schedule new family member/roommate diet change other If otherHow did these changes affect your pet?Please indicate any other behavior problems house soils destructive chewing feeding sexual grooming digging swallows nonfood items shy eats stool pacing aggressive barking learning sleep play jumps up unruly bites fights runs away destructive scratching other If otherPlease describe all situations which are likely to elicit aggressive behavior such as growling, nipping, biting, attacking, etc. (e.g. petting, approached by anyone, approached by children, only when in the car, reaching for, punishing, pushing, taking food or toys away, disturbed while sleeping, etc.):If your pet has an aggression problem, describe at least the last two or three aggressive incidents in detail. Please discuss in detail any other information that you feel is relevant to your pet's problem:CAPTCHA
