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Patient Intake Form: Behavior Department

Owner First Name

Owner Last Name

Address

Phone Number

Pets Name

Species

Breed

Sex

Age

Color

PLEASE MARK ALL OF THE APPROPRIATE BOXES AND FILL IN THE BLANKS TO THE BEST OF YOUR ABILITY

We may take pictures and videos as a part of your pet's appointment. Below is a consent form for use of images of your pet. When used, there will be no identifying information of the pet or yourself, such as your name. Please consent below to whichever options works best for you.

We may take pictures and videos as a part of your pet's appointment. Below is a consent form for use of images of your pet. When used, there will be no identifying information of the pet or yourself, such as your name. Please consent below to whichever options works best for you.

Who is your pet's primary care veterinarian?

Please list all veterinary hospitals where your pet has been seen in the past 5 years.

I am the owner(s) of the animal(s) seeking behavioral medicine treatment from Gold Coast
Center for Veterinary Care. Behavioral treatment, training and advice when properly maintained after completion can be very helpful in resolving problem behaviors in animals. Because each pet is an individual, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior including aggression is unpredictable and will remain unpredictable after its treatment. Gold Coast Center for Veterinary Care cannot promise that the animal's behavior service treatment, training or advice will completely eliminate the animals potential danger to persons or completely control the animals aggressiveness. Animals should be closely supervised particularly around children and infants and should be controlled at all times including conformance with local ordinance and "leash laws".
I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.
I understand that all fees are to be paid tat the time of service and accept full responsibility for the charges incurred in the treatment of my pet.
Telehealth appointments may be recorded for internal training only.
DOG BEHAVIORAL QUESTIONNAIRE

How long have you had your dog?

Where did you get your dog?

Has your dog had any other owners?

Has your dog had any other owners?
A
B

If so, how many?

If applicable, please explain why your dog was relinquished by the previous owners

How many people are in your household?

Has there been any significant change in your household's routine or schedule in the past 3 months?

What are your goals for this appointment?

Are there any children in the house or who come to visit regularly?

Are there any children in the house or who come to visit regularly?
A
B

If you feel that the relationship of the patient with a particular person is important to the assessment and treatment of the problem for which you are bringing your dog, please describe.

Tell us about your pet's environment. Check all that apply:

Tell us about your pet's environment. Check all that apply:

How many play sessions does you dog get per day?

If you have multiple pets, please answer the following questions.

Does your pet sleep with the other pets?

Does your pet sleep with the other pets?
A
B

Lick or groom the other pets?

Lick or groom the other pets?
A
B

Play with your other pets?

Play with your other pets?
A
B

List the other animals in the household and describe their relationship with the patient

MEDICAL HISTORY

Please describe any significant medical illnesses, treatments, and the outcomes

What do you feed your pet?

Does your pet have any allergies or food sensitives?

Please check all the previous treatments tried:

Please check all the previous treatments tried:

Does your dog lick (you, the floor, himself, other objects, other people)
excessively?

Does your dog lick (you, the floor, himself, other objects, other people) excessively?
A
B

Have you ever worked with a dog training professional with this pet before?

Have you ever worked with a dog training professional with this pet before?
A
B

Have you worked with a dog training professional in the past three months?

Have you worked with a dog training professional in the past three months?
A
B

If you have worked with a dog trainer previously, please list the company and the trainer's name and what behaviors were taught. Include puppy classes. This helps us to know what behaviors and methods have been used thus far in training your dog.

Are you planning to continue to work with the dog training professionals listed above?

Are you planning to continue to work with the dog training professionals listed above?
A
B
SLEEPING BEHAVIORS

Does your pet sleep through the night?

Does your pet sleep through the night?
A
B

Have you noticed any change in your pet's sleeping patterns in the past three months?

Have you noticed any change in your pet's sleeping patterns in the past three months?
A
B

Does your pet take naps during the day when you are home?

Does your pet take naps during the day when you are home?
A
B
AGGRESSION SCREEN
If your dog has shown aggression (biting, lunging, barking, growling) please fill out this section. If not, please skip.

Are there people in your household or who regularly come to visit who are at greater risk if bitten?

Are there people in your household or who regularly come to visit who are at greater risk if bitten?
A
B
Untitled multiple choice field
A
B
C

Has your dog ever bitten a person?

Has your dog ever bitten a person?
A
B

Number of bites?

Number of bites that broke the skin?

Number of bites that were reported to pubic heath authorities?

Has your dog ever bitten a dog?

Has your dog ever bitten a dog?
A
B

Number of bites?

Who is your dog aggressive toward? Check all that apply

Who is your dog aggressive toward? Check all that apply

When is your dog aggressive? Check all that apply

When is your dog aggressive? Check all that apply

What does your dog look like when he is aggressive? check all that apply

What does your dog look like when he is aggressive? check all that apply

When visitors enter the home? Check all that apply

When visitors enter the home? Check all that apply

Please check all previous treatment tried:

Please check all previous treatment tried:

Please add any additional information that you would like to share about how, when or to whom you pet is aggressive.

STORM/SOUNDS
If your dog exhibits fear or anxiety during storms or loud noises please fill out this section.

Of what sounds if your dog afraid of? Please check all that apply.

Of what sounds if your dog afraid of? Please check all that apply.

What does your dog do when he hears a scary sound? Check all that apply.

What does your dog do when he hears a scary sound? Check all that apply.

Other:

How long does it take after a sound for your dog to calm down entirely?

Please add any additional information that you would like to share about your dog's reaction to scary sounds

SEPARATION BEHAVIORS

Does your dog follow you around the house?

Does your dog follow you around the house?
A
B

How does your dog reach when you prepare to leave

How does your dog reach when you prepare to leave
A
B
C
D
E
F
G
H
I

How does your dog behave when you return?

How does your dog behave when you return?
A
B
C
D
E
F
G

Where is your dog when you are not home??

Where is your dog when you are not home??
A
B
C
D
E
F
G
H

Other:

What does your dog do when you are not home? check all that apply

What does your dog do when you are not home? check all that apply

Other:

Does your dog exhibit the behavior every time that you depart?

Does your dog exhibit the behavior every time that you depart?
A
B

Does your dog exhibit the behavior only when alone?

Does your dog exhibit the behavior only when alone?
A
B

Please add any additional information that you would like to share about your dog's anxiety or panic when you leave

ANXIETY/DISTRESS IN THE CAR
If your dog exhibits any anxiety or distress when riding in the car please fill out this section.

Please check all that apply to your dog's behavior when riding in the car:

Please check all that apply to your dog's behavior when riding in the car:
DISPLACEMENT/COMPULSIVE BEHAVIORS

Does your dog do any of the following:

Does your dog do any of the following:

Did someone recommend euthanasia before your visit to us?

Did someone recommend euthanasia before your visit to us?
A
B

Have you considered euthanasia before this visit?

Have you considered euthanasia before this visit?
A
B

Have you considered re-homing your pet before your visit?

Have you considered re-homing your pet before your visit?
A
B

Anything else you'd like to share with us about your pet?