Common Behavioural Signs of Fear, Anxiety and Stress (FAS) Pet Information__________________________________________________________ MILD - 1 MODERATE - 3 SEVERE - 5 • Lip lick • Yawning • Lowered tail • Eye avoidance • Turning head • Ears back • Salivation • Excessive licking • Moving body away from stimuli • Body lowered to ground • Tail tucked • Spinning or jumping • Freezing or Pacing • Vocalization - whining, barking • Not interested in treats • Mounting • Tremble • Urination or defecation • Fully dilated pupils • Whale eye • Growling, lunging • Snapping • Vocalization - scream Date of Birth:_____/_____/_____ BREEDER RESCUE REHOME N Pet’s Name: ___________________________________ Sex M F Age Obtained: ______________ Spayed/Neutered___ If so, at what age?____________ Breed _________________________________________ Is your dog up to date on vaccines (DA2PP and RABIES)? Y Canine Behaviour Questionnaire Bordetella (kennel cough)? Client Information ___________________________ Name:_________________________________________ Address:_______________________________________ Phone Number: H (___) ____-____ C (___) ____-____ Email Address:_________________________________ For what purpose was your pet obtained? _____________________________________________________________________ Briefly described your dog’s personality (e.g. quiet, confident, excitable, unruly, bold, etc.) _________________________________________________________________________________________________________ Behaviour of parents or littermate(s): _________________________________________________________________________ Are there any other pets living in the home? If so: provide species, age, name and neuter status? Current health issues: _________________________________________________________________________ List all medications and supplements (including parasite preventions): None 1. ________________________________________________________ Dose: _________ Time:_________ 2. ________________________________________________________ Dose: _________ Time:_________ 3. ________________________________________________________ Dose: _________ Time:_________ 4. ________________________________________________________ Dose: _________ Time:_________ 5. ________________________________________________________ Dose: _________ Time:_________ Allergies: ___________________________________________________________________________________
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Common Behavioural Signs of Fear, Anxiety and Stress (FAS)
Pet Information__________________________________________________________
• Salivation• Excessive licking• Moving body away from stimuli• Body lowered to ground• Tail tucked• Spinning or jumping• Freezing or Pacing• Vocalization - whining, barking• Not interested in treats• Mounting
Environment and Lifestyle __________________________________________________________________
House Type (i.e. single family, apartment, etc.): _________________________ Backyard?__________________
How many people live in your home?__________ How many children live in your home? ________________
If there are children in your home, please list their ages: _____________________________________________
Where does your dog sleep? _____________________________________________________________________
Where does your dog rest during the day?_________________________________________________________
Type of Food:_____________________________ When is your pet fed?__________________________________
Who feeds your dog?__________________________________ Where is your dog fed?_____________________
List your dogs FAVOURITE treats: _________________________________________________________________
Describe your dogs daily routine (including type and length of exercise, and who exercises the dog):
What type of games do you play with your dog? __________________________________________________
Who plays with the dog in the household ?________________________________________________________
Does your dog regularly interact with other dogs or species?
Training ____________________________________________________________________________________
Has this pet had obedience training? CLASS PRIVATE TRAINER TRAINED AT HOME
Please indicate the type(s) of training collar used: ___________________________________________________
Do you currently use or have used a choke collar, prong collar or electric collar?_________________________
Is your dog completely housetrained? __________ Do you use pee pads or other:________________________
Is there on-going training? If so, describe (including style of training and methods used, tricks, etc.):
Who has the most control of the dog in the household? _________________ Who has the least? ___________
Handling and Grooming ___________________________________________________________________
How does your dog react to the following, please describe:
• Nail trimming:
• Brushing:
• Towel drying:
• Head handling:
• Collar touch:
• Ear cleaning and medication:
• Hugging:
• Being lifted:
• Restraint:
How does your dog respond to the following cues: (use Immediately, Not Known, Sometimes, Only with Treat, Never)
• Sit: ____________________________
• Sit Stay:________________________
• Down:__________________________
• Down Stay:______________________
• Watch Me:_______________________
• Name:__________________________
• Recall in House: ____________________________
• Recall Outside:_____________________________
• Leave it/ Drop it:____________________________
• Settle:_____________________________________
• Heel/Loose Leash:__________________________
• Any tricks?________________________________
Departure Behaviours _______________________________________________________Please provide a brief description of when and where the following behaviours occur:
• Jumps on strangers: ____________________________________________________________________
• Jumps on visitors: ______________________________________________________________________
What is your primary concern to be addressed during this behavioural consultation?
When did this problem begin? ____________________________ How often does it occur?_______________
What do you believe may have triggered or caused the problem?
Please describe the most recent event:
Can you describe the first incident?
Has there been an increase in the frequency of the concern? _______________________________________
Were there any changes to the environment, the dog’s health or family change when the behaviour was
first seen?__________________________________________________________________________________
Have you tried to correct the problem? If so describe:
How did your dog respond to intervention?
Has drug therapy been recommended by Dr. Vieira or Dr. Robertson? If so, please comment on your understanding and opinion of supplemental drug therapy: