GPH Behavioural Consultation Questionnaire

Location

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In addition to this questionnaire, any videos or images of the behaviour in question would be very helpful but only if they can be safely obtained.

Pet's First Name*

Pet's Last Name*

Last Name on File (if different from above)

Describe the problem you are currently experiencing with your dog:

How old was the dog when the problem began?

Is this a chronic (constant) or intermittent problem?

Where does the problem commonly occur?

With whom does it occur?

How often does it occur?

If the problem is house soiling, does it occur when you are home and/or away?

If the problem is destructive behaviour, does it occur when you are home and/or away?

Any additional details about the problem:

Is there any legal action pending because of this dog’s behaviour?

If the current problem is not aggression related, has your pet ever displayed signs of aggression? If so, or if the current problem is aggression related, please proceed to the next section.

Describe the most recent incident and the setting in which it occurred (be precise):

Where was the dog?

Where was everyone else in relation to the dog?

What was everyone doing prior to the incident?

What was the dog’s body posture (position of ears, tail, face, hair on back)?

What was your reaction or response?

What was the dog’s reaction to your response?

Was any form of punishment used? If so, give details:

Was there a bite wound, please describe (i.e. puncture? Tear? Broken skin?):

Describe the previous three incidents prior to the most recent incident:

How frequently does this type of incident occur?

Does this problem occur when the dog is left alone?

Does this problem occur when family members are present?

What has been done to correct the problem?

Is the problem getting better or worse?

Do you suspect any cause?

Security Question*

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY **

Behaviour Consultation Questionnaire