Kingsbury Animal Hospital

420 North Skinker Blvd.
Saint Louis, MO 63130

(314)721-6251

kah.com

New Behavior Consultation Form

BEHAVIOR HISTORY FORM
Client Information
Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Phone (required)
Phone TypePhone Number (required)
Secondary Phone
Phone TypePhone Number
E-Mail Address :
Referral (required)
Rose Wekenborg
Gateway Men's Chorus
Drove by
Happy Tails
Pride Pages
Vital Voice
Walk In
Word of Mouth
Yellow Pages
Pride Festival
West End Word
Doctor Referral
Wolfgang's Pet Shop
St. Louis Tails
Y98 FM Radio
City/County Animal Control
Angie's List
APA of Missouri
YELP
St. Louis Training Club
Tenth Life
Pet Smart
Lucy Bailey
Google
Wash U Medical Center Housestaff
Other
If your referral was "other" or a specific person, please specify:

Best method for contact (required)

Patient Information
Name: (required)

Color (required)

Age: (required)

Gender
Male
Female


Neutered/Spayed
Yes
No


Species
Canine
Female


Breed

Medical History (only for new clients to Kingsbury Animal Hospital)
Date of Last Physical Exam:

Other medical tests performed associated with behavioral issues:

Age of Spay/Neuter:

If still intact, do you plan on breeding your pet?
Yes
No


Are all vaccines current?
Yes
No


Please list all medications your pet is currently on:

List all medications, including homeopathic remedies, your pet has ever had for behaviorial issues:

Does your pet have preexisting or current medical problems? :
If yes, please list:

Has your pet ever had a seizure?
Yes
No


If yes, please provide date(s) and approximate lengths of seizure(s):

Household Information
Please list everyone in your household, including ages of children and hours away from home:

Please list all household pets, including the patient, in order they were acquired:

Background Information:
How old was your pet when you first acquired him/her?

Where did you acquire your pet?
stray/found
professional breeder
hobby breeder
shelter
breed rescue group
newspaper/Craigslist adoptions (not breeder
pet store
friend/relative
other


Why did you get this pet?
family pet
working dog (hunting)
protection/guard dog
for breeding
other


Describe your pet when she was a puppy/kitten:
friendly
shy
outgoing
fearful
aggressive
playful


Is your pet (please check all that apply):
allowed to run free, unsupervised when outside
always enclosed in a contained area when not on leash
leash-walked
outside, unleashed, but supervised
outdoors only


How many times is your pet walked per day?

If your pet is walked, what is the average length of time for each walk (in minutes)?

Who walks your pet?

What type of collar/ leash do you use to walk your pet?

What percentage of the days does your pet spend inside?
0-25%
25-50%
50-75%
75-100%


Have you had pets before?
dogs
cats
other
none


What kind of living situation do you have?
apartment
townhouse/condominium
house with small yard
house with large yard
farm/rural property


Is your pet allowed on furniture?
yes, all furniture
yes, only on specific pieces
yes, only if invited
no, but gets on anyway in presence and absence of people
no, but gets on anyway in the absence of people
no, to my knowledge never gets on furniture


Is your pet fed:
free choice (bowl is kept full of food)
one meal per day
two meals per day
more than two meals per day


Where is your pet when left home alone?
free in house
outside house
in crate
restricted to certain areas in house


Please describe area if you chose "outside house" on last question.

Is your pet fed treats on a daily basis?
yes
no


Do you play with your pet routinely?
yes
no


If yes, please describe a typical play episode.

Describe how you prepare to leave pet alone at home. Do you ignore pet, put in crate, say goodbye?

FOR DOGS ONLY
What is your dog's obedience school history?
no school, trained yourself
puppy kindergarten
group lessons, basic
group lessons, advanced
private trainer at house
private trainer, sent to trainer


Please choose how well your dog obeys the following commands.
sit
perfect
usually
needs work


stay
perfect
usually
needs work


lie down
perfect
usually
needs work


come
perfect
usually
needs work


heel
perfect
usually
needs work


fetch
perfect
usually
needs work


drop it
perfect
usually
needs work


watch me
perfect
usually
needs work


Is your dog trained to go to certain spot/location (e.g. bed, crate, mat) on a verbal command?
yes
no


If yes, how reliable is the response?
Perfect
Good
Moderate
Poor


For Cats Only:
How many litter boxes do you have?
0
1
2
3
4
more than 4


Describe the litter boxes:
open
covered
large
small
liner
no liner


If you chose more than one answer in the previous question, how many of each type of box do you have

Where are the litter box(es) located? Check all that apply.
closet
kitchen
bathroom
bedroom
attic
laundry room
living room
basement
stairwell
other


What kind of litter do you put in the boxes? Check all that apply.
clumping litter
plain clay
scented
unscented
playground sand
large pellets
wheat litter
cedar chips
varies with each purchase
other


Is your cat declawed?
no
yes, front declawed only
yes, all four feet declawed


Does your cat use a scratching post?
yes
no


Does your cat have any outdoor access?
yes
no


Reaction to Handling by Family Member
Text Block
For the following situations, please indicate whether your pet has shown aggression. This can include growling, hissing, snarling (showing teeth), lunging, nipping, snapping, or biting. Please indicate whether the aggression was/is shown to : adult owner (male), adult owner (female), children, any other specific individual. If biting occurred, please describe the wound (tear, puncture, bruising). If no aggression occurred during the specified situation please write "none".
Handling/Grooming

Petting or hugging

Disturbed when resting

Disciplining

Walking on lead

Taking food away

Taking other objects

Behavioral Problem:
Other situation (please describe):

List behavioral problem(s) and if you consider them: very serious, serious, or not serious.

Describe a typical episode of the behavioral problem(s):

How often does the behavior occur? (times per day/ week/ or month)

Describe the first incident (including date):

Describe the most recent episode (including date):

Has the frequency of the behavior
increased
decreased
remained the same


Has the intensity of the behavior :
Have there been any changes at home (new pet, new family member, schedule change)? Please describe.

Have you considered finding another home for your pet? :
What have you tried to do to change the problem? Please list all things and if they were useful.

Have you considered euthanasia (putting your pet to sleep)? :
Is there any other information you would like to add?

Text Area


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