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Behavior History Form - Dog / Cat

Owner Name *

Co-Owner *

Address *

City *

State *

Zipcode *

Cell Phone# *

Secondary Phone# *

Email Address *

Primary Vet Clinic and Veterinarian *

Last Checkup *

Pet's Name *

Pet Type *
DogCat

Age *

Breed *

Sex *

Spayed/Neutered *

Date of Adoption or Purchase *

Age of Adoption or Purchase *

Name/Location of Rescue/Breeder *

Primary Complaint *

How Long? *

Secondary Complaint *

How Long? *

Number of previous homes? *

Ages and number of people living in your home and regular visitors (stepchildren, grandchildren) *

List moves, new people or pets in the home, or those no longer at home over the past 12 months *

List all pets and their ages and breed living presently in the home *

EXERCISE:

# of Walks per Day *

# of Yard Times per Day *

# Play with Human *

# Play with another Pet *

Pet Day Care *

# of Times per Week *

Home Pet Sitter *

# of Times per Week *

Changes in exercise/play/getting on resting places or perches *

MEDICAL CONSIDERATIONS:

Skin problems *

Vomiting/Loose Stool *

Ear problems *

Stiff joints/Slow to get up *

Medications for Health Condition *

Medications/Supplements/Products used for behavior problems *

Past physical injury or surgery – knee surgery, hit by car, fell out of tree, etc. *

Which family member is the primary caregiver for pet? *

List brand, amount, location and time of day your pet is fed *

Additional treats/table food/getting into garbage or eating other pet’s food – please list *

ANY ACCIDENTS IN HOME:

Dog *

Cat *

Stool *

Urine *

Number of litter boxes *

Number of times scooped per day *

Dumped and cleaned per week *

Brand/type of litter *

Location of litter boxes *

# of stools/day *

# urination/day *

I cannot tell as I do not see my pet go/shared box *

Where does your pet sleep? (in kennel, pet bed, in bed with you, etc.,) *

Has your dog/cat every chased down small animal? *

Has your dog/cat ever grabbed at anyone’s clothing or arms/legs If yes describe exactly what happened? *

If skin broken – how deep was bite *

# of bites incidents *

DOES YOUR DOG?:

Bark *

Pull *

Jump at *

at things outside *

at the door *

on walks *

at dog park *

Has your pet ever avoided people in your home? Hid under bed/table/ leaves the room or area regularly *

Is anyone more affected than others? If yes, who? Please describe as best you can. *

In full detail describe the incidents of the primary problem behavior, from the first incident you can recall, including what you have tried to resolve the problem. Include description of other behavior problems after the primary problem description. *

What is your expected/desired outcome for you & your pet? *

I hereby authorize the veterinarian to consult via telehealth or other means for the evaluation of the behavior of my animal. No diagnosis, prognosis or prescription of medication is provided. Photos and video of my animal in home or other settings submitted to Dr Foote will be used for assessment, and I allow use of these videos to other behaviorist, DVM or for educational use for DVM or animal professional. I assume responsibility for all charges for this and any future consultations. *
YesNo

We require a $60 deposit to be made when you schedule your appointment. The deposit is non-refundable

If Dr Foote has not physically examined my pet, the video chat is a Teletriage/teleadvice consult. Dr Foote will not be prescribing medication, making a diagnosis or prognosis about my pet. Dr Foote will collaborate with my primary care veterinarian who will be the one to prescribe medication, make a diagnosis or prognosis about my pet.

Telecommunication with the veterinary staff is limited to the hours of availability determined by the veterinary staff.

Signature of Owner/agent *

* Payment is due upon receipt of invoiced services. A $5 MINIMUM OR A 2% MONTHLY CHARGE IS ADDED TO ALL BALANCES. * Any unpaid balance over 60 days will be send to collections, with all fees for collection services added to the balance for services.