Canine Behavior History Form

Animal Behavior Consultants of Northern Michigan
Dr. Katherine A. Houpt
Phone: (989) 448-8083

Please answer the following questions and submit this form. We shall then call to arrange an appointment. Specific questions about the problem behavior(s) will be asked during your visit.

General Information

* Indicates required field

Who is your regular veterinarian:

Behavior Problem

  1. Behavior ProblemSeverity

Chronology of the Behavior Problem

  1. Describe several examples in detail: When, where and what other animals or people were present.
    1. ( )
    2. ( )
    3. ( )

Home Environment

Dog's Background

Diet and Feeding

Daily Schedule

Obedience Training

  1. Family MemberSitDownStayComeHeel
    (Don't Pull)

Medical History

  1. (1 year, 3 year)

Aggression Screen

  1. Please fill out using the following Behavior Codes:
    • GR - growl
    • SL - snarl/bare teeth
    • SB - snap/bite
    • NR - no reaction
    • NA - not applicable
    1. pet dog
    2. hug dog
    3. kiss dog
    4. lift dog
    5. call off furniture
    6. push/pull off furniture
    7. approach on furniture
    8. disturb while resting/sleeping
    9. approach while eating
    10. touch while eating
    11. take dog food away
    12. take human food away
    13. take water dish away
    14. take rawhide
    15. take biscuit/cookie
    16. take real bone
    17. take toy/object
    18. approach when dog has any object/toy/bone
    19. verbally punish
    20. physically punish
    21. visual threat
    22. speak to dog (normal tone)
    23. stare at dog
    24. bend over dog
    25. push on shoulders or back
    26. approach dog near spouse
    27. enter room
    28. leave room
    29. reach toward dog
    30. leash restraint
    31. collar restraint
    32. scruff restraint
    33. put leash on/take off
    34. put collar on/take off
    35. bathe dog
    36. towel dog
    37. groom/brush dog
    38. dog at groomer's
    39. trim nails
    40. leash/collar correction
    41. response to "sit"
    42. response to "down"
    43. dog at veterinary clinic
    44. unfamiliar adult enters house or yard
    45. unfamiliar child enters house or yard
    46. familiar adult enters house or yard
    47. familiar child enters house or yard
    48. response to toddlers/babies
    49. dog in car at tollbooths, gas stations
    50. unfam. adult approaches owner, dog on leash
    51. unfam. child approaches owner, dog on leash
    52. dog in house, sees people outside
    53. response to other dogs, while on leash
    54. response to other dogs, while not on leash

Aggression Towards People

(Skip this section if aggression is not the problem)
  1. Please answer these characteristics of your dog's aggressive behavior:


(End of questionnaire, please submit - thank you!)