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: ___________________________________________________________________________________

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: ______________________________________________________________________

• Repetitive behaviours (i.e. pacing):________________________________________________________

• Mouths or grabs at hands: _______________________________________________________________

• Barks or whines: _______________________________________________________________________

Is your dog crate training, in a pen,or a room or allowed to roam freely when alone?__________________

For how long is your dog left on average per day?_______________________________________________

How does your dog react when you are getting ready to leave?____________________________________

Has your dog been to a kennel, or left with someone else while you were away?______________________

If yes, how did they react to your absence?_____________________________________________________

Has your dog destroyed anything while left alone?_______________________________________________

How does your dog act on return?____________________________________________________________

Aggression and Reactivity__________________________________________________

Please answer and describe the following to the best of your ability

Has your dog ever displayed treat behaviours (hackles raised, snarling, barking, snapping, lunging)? _______

• Growling? ___________________________________________________________________________

• Snarling or showing teeth?_____________________________________________________________

• Lunging?____________________________________________________________________________

• Bite attempts?________________________________________________________________________

• Bites?_______________________________________________________________________________

o Any damage inflicted from a bite wound (human or other animal)?_________________________

o Was medical or veterinary attention sought?__________________________________________

o Date of last incident:________________________

What situations typically lead to the above behaviours? And who is the family or outside of family is the main target (human or animals)?

Does your dog display any reactivity towards strangers or visitors?

Is there a specific person or type (sex, age, uniform) that your dog will aggress towards?

Is there a specific environment or event that will reliably predict an aggressive response?

Is there a specific dog (breed, size, colour) that will reliable predict an aggressive response?

Describe your dog’s attitude and body position leading up to and during the aggressive event.

Other relevant behavioural information:

Fear, Anxiety and Stress Stimulus Screening __________________________________ STEP 1 STEP 2 STEP 3 STEP 4

Below are common triggers of Fear, Stress and Anxiety in dogs.

Score all that apply.

What level of FAS does your dog experience for his triggers?

Use signs listed on the first page to score 1 = MILD, 3 = MODERATE 5 = SEVERE

What is the typical length of time signs are exhibited?

1 = Only during trigger 2 = More than 5 minutes

How often is your dog exposed to each trigger?

1 = Rarely exposed 2 = Several times per month 3 = Exposed daily

Thunderstorms, fireworks or sharp noises

What trigger?____________________

Confinement in crate or pen

Left alone in home

Car rides Do you travel often? Y es No

New objects or environments

Unfamiliar person enters the home

Greeting unfamiliar dog outside the home

Approached by child Are their children at home? Yes No

Approached by another household dog

Handling by family member (toweling off, restraining, nail trim, etc.)

Handling by non-family member (groomer or vet)

Does your dog experience any behavioural signs listed on the previous page that are not associated with any of the above triggers? If so, please list:

Primary Concern ____________________________________________________________

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:

Other notes relevant to primary concern:

Secondary Concern _________________________________________________________

What is your secondary 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?

Other notes relevant to secondary concern:

Thank you for filling out the questionnaire, please send your responses to staplesanimalhospital@gmail.com.