Canine Behavior Consultation History Form Bottletree Animal Hospital Canine Behavior Consultation History We are so excited to see you and your pet at Bottletree Animal Hospital! We ask that you complete this history form at least 24 hours prior to your appointment time. This will help us provide the most thorough care for your pet. You may save your input and return to the form later if necessary. Name * Name First First Last Last Email * Have we seen your pet(s) at Bottletree Animal Hospital before? * Yes No Maybe Name of Pet * Breed of Pet * Sex of Pet Male Female Spayed / Neutered Yes No Unknown Where did you acquire your pet from? * (Breeder, friend, adoption, Petsmart, etc.) How long have you owned your pet? * Why did you acquire your pet? * Please provide a basic description of the behavior problem(s). * When did the problem happen, how often does it happen, and how severe is the problem? Please describe any attempts that have been made to resolve the behavior problem(s). * This includes disciplinary consequences, training, changes in environment or routine, medication, etc. Please describe the outcome of these attempts and whether this change is still in place. What are your expectations or goals for your pet's behavior? * Describe your goals for this consultation and your long-term goals for your pet. Please select the statement that most accurately represents how you feel about this/these behavior problem(s): * I am curious about the problem, but it is not serious. I would like to change the problem, but it is not serious. I would like to change the problem and it is serious, but if it does not change that's alright. The problem is very serious and I would like to change it, but if it remains unchanged I will keep my dog. The problem is very serious and if it remains unchanged I will euthanize or rehome my dog. Does your pet have any history of medical conditions? * (Surgeries, chronic diagnoses, serious or recurrent illness, allergies) Please list any medications your pet is given, including dose and frequency. * Please list any supplements your pet is given, including dose and frequency. * Please list any parasite prevention (for fleas, ticks, heartworms, etc.) you use for your pet. * If you are human, leave this field blank. Next
