Behavior Questionnaire Form

Save time at your pet’s behavioral consultation! Complete your required form online before your visit.

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Name *

First

Last

Preferred Phone *

Secondary Phone Number *

Email *

Pet's Name *

Species *

Breed *

Sex *

Age *

Weight *

From where and at what age did you obtain this pet? *

List all major surgical or medical problems *

List all medications (including dosage and schedule) currently being taken *

Describe your pet's behavior problem(s) *

Describe the situation(s) in which the problem(s) occur *

When was the problem(s) first noticed? *

List any changes in frequency or appearance of the problem(s) *

What has been done so far to correct the problem (training, confinement, discipline, etc)? *

What was the pet's response the correction(s)? *

Have any medications or supplements been prescribed for problem(s)? If yes, what were the results? *

Were there any changes to the pet's environment prior to the appearance of the problem(s)? *

Is there any additional information you would like to add? *

Name