Helen Taylor, Certificated Clinical Animal Behaviourist (CCAB)
1 Plowman Close, Marnhull, Sturminster Newton, Dorset, DT10 1LB
Tel: 07951 985193    Email: info@helentaylordorset.co.uk    web: www.helentaylordorset.co.uk

Canine Behavioural History Questionnaire
PLEASE READ  ALL THESE INSTRUCTIONS, AND THE CONSULTATION GUIDELINES PROVIDED SEPARATELY,  BEFORE STARTING TO COMPLETE THIS FORM. 

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Please be honest.
Please be detailed
 Please complete all questions

Date of Consultation(s):   				Form Date:21/4/25

PLEASE READ THE CONSULTATION GUIDELINES BEFORE RETURNING THIS QUESTIONNAIRE

Section 1 Background and History		

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Date questionnaire completed:					Questionnaire completed by:

Please briefly (in one or two sentences) sum up your dog’s main problems (as they stand now), and why you are seeking help NOW. 

IF YOU NEED A SHORT ZOOM PRACTICE SESSION PRIOR TO THE CONSULTATION, OR  NEED ADDTIONAL GUIDANCE ON WHAT VIDEO CLIPS I DO (AND DO NOT) NEED TO SEE, PLEASE CONTACT ME SEPARATELY WELL IN ADVANCE OF THE CONSULTATION. 

Which report option you would like (see consultation guidelines for prices) SUMMARY or FULL: 

SUMMARY      /        FULL            (Delete those that don’t apply)

(Please note that it is not possible to change this without rescheduling the appointment)

Would you like a copy of the zoom consultation (see consultation guidelines for prices)?

Name(s) and address of owner(s):					 

Occupation (yours and partner/spouse): 

Dog’s name: 					Breed/Type:  				 

Tel Landline(s): 			  Tel (Mob): 	

Email address (will be used to send your report(if requested), and also invitation for Zoom meeting):
NB please check your email spam/junk folders when expecting an email from me.
	
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Dog Sex: 			Date of birth (if known): 				 Age:  

Is your dog neutered? 			 If yes, what age was s/he neutered and why: 

Did the behaviour change after neutering?  

For Female dogs, was your dog neutered LESS than 16 weeks after the END (or 20 weeks after the START) of the preceding season? 

For Female Dogs – does/did her behaviour change with seasons or phantom pregnancies? 

Is your dog insured?  			  Name of insurer: 			

If relevant, are you intending to claim the cost of the consultation back on your insurance? 

If using Zoom, would you like the session to be recorded:

Please note that I cannot guarantee that the Zoom recording will be successful (like all technology, there are occasional failures outside of my control). 

Who recommended you/How did you find me? 

What was the trigger for seeking help NOW particularly? 

PLEASE COMPLETE THESE THREE FIELDS IN FULL BEFORE RETURNING THE FORM - THE CONSULTATION CANNOT GO AHEAD WITHOUT A REFERRAL FROM A NAMED VETERINARY SURGEON:

1. Full name of referring veterinary surgeon (cannot be a nurse or receptionist): 

2. Referring veterinary practice name and full address 

3. Method of referral – please tick one of the following 
[  ] Referral form signed by vet– already returned by you/vet to Helen Taylor by              (enter: post/fax/email)
[  ] Referral form signed by vet – will be returned by you/vet to Helen Taylor by             (enter: post/fax/email) by        (date).
[  ] Referral form will be or is signed – kept by owner until the consultation date
[  ] Veterinary surgeon named above to email medical history direct to Helen Taylor (client to arrange)

Diet:

Food (please include brand and variety): 

How many times a day is your dog fed? 

Do you give any supplements, treats or chews? If so, please list these and purpose: 

Has diet been changed recently? If so, please state previous diet, when changed and reason for change: 

Does your dog eat every meal within 10 minutes of it being put down (unless ill)? 
 
Has he ever been raw fed?  			How food motivated would you say your dog was? 

Are there any foods that your dog is allergic to?

Medical History:
Does your dog have any current or previous medical problems to your knowledge? Please list ALL past or current medical issues (no matter how minor)  if details not provided separately (eg referral form or emailed medical history).

Has your dog ever suffered from any stomach or gastrointestinal symptoms?

Is your dog on any current medication? Please give name, dosage and reason: 

Family and household:

Who lives here (please give names and relationships of everyone, and ages of all children)?

Who else (human or canine) is a very regular visitor:

If you have children, please describe how they interact with the dog: 

Does your dog have different relationships with different family members?

Do you have any other animals? Please detail type, age and sex and describe how all animals get on: 
NB if you have another dog you also require help with, or this case involves the other dog please complete one form for each dog. 

Very briefly, what is the family’s routine? 

Have you moved house or had any other significant family change in the last year, or around the time the behaviour problems started?

Early History and socialisation:

How old was your dog when you obtained him/her? 			How long ago? 

Full background before current owner (as much as is known): 

What was your puppy/dog like when you picked him up and  when you first brought him home? 

Did s/he show any fear or avoidance of anything even briefly?

Breeder setup: (If you did not obtain your dog from the original breeder you may skip the section in the box)
Did you meet both parents? If so, describe their apparent temperament in particular whether either parent, or another dog in the household, showed any signs of fear or aggression and how calm (or not) they appeared to be: 

Do you know of any problems with parents or siblings? Describe:

Were the puppies raised inside a home or outside (eg in a stable or shed)? Describe the puppies’ circumstances including whether they would have met children or other animals: 

How quiet or busy would you describe the puppies’ early environment as?

What age did your puppy have vaccinations and what age did you start taking him out? 

Did you carry your puppy “out and about” before his vaccinations had taken effect? If so, describe:

Describe what you did to socialize your puppy (with people, dogs and environments) between obtaining him/her and 14 weeks of age. 

Only counting encounters where your dog has sniffed/greeted a person/dog and has done so willingly and without aggression or fear, please estimate numbers of unfamiliar/new dogs and unfamiliar/new people met 
In total, between leaving the breeder and reaching 16 weeks of age
Human			 of these, how many children and what ages:  
Dog: 

Only counting encounters where your dog has sniffed/greeted a person/dog and has done so willingly and without aggression or fear, please estimate numbers of unfamiliar/new dogs and unfamiliar/new people met
In an average month, between 16 weeks and 1 year of age
Human: 		of these, how many children and what ages?
Dog: 
 
In an average month after 1 year of age:
Human: 		of these, how many children and what ages?
Dog: 

Traumatic Experiences
Has your dog suffered any traumatic experiences - either before or after onset of behavioural problems (in roughly chronological order):

Date or age of dog	Incident

Punishment

Have you – or anyone else - ever used any form of punishment on your dog apart from a mild verbal reprimand? Examples include smacking/tapping nose (or threatening), rolled up newspaper used on dog or furniture, shouting, lead jerks, noise devices (eg ultrasound or Pet Corrector), water sprays, Rattle cans/bottles.  Please include use of choke chain, slip lead, or any type of collar that emits something (eg emits a spray, noise, shock, vibration etc). Please give  details below including purpose of punishment/device, what this was for, what the dog’s reaction was and when/how long it was used for:

Date or age of dog (to/from)	Punishment used

Have you done anything else to try and discourage any of the undesired behaviours (even if you don’t consider them punishment)

Section 2: Your dog’s behavioural problems 
Listing each main problem separately, please describe in detail how each of your dog’s main behavioural problem(s) have developed.
Treating each main problem separately, please describe your dog’s behaviour and list any significant incidents in chronological order, giving your dog’s approximate age at the time, starting with his behaviour in that situation before you noticed any problem and ending with the situation as it stands currently. Please give as much detail as possible. Each of the following counts as a single main problem and needs to be listed separately (although this does not necessarily mean that they are not related): aggression towards unfamiliar people (eg visitors), aggression towards the owners/familiar people, aggression towards children, aggression towards unfamiliar dogs, aggression towards familiar dogs (eg house-mates), chase/recall problems, separation problems, noise phobias, house-soiling (this is not a complete list). Continue on another sheet if necessary. 

If aggression is involved, please detail whether your dog ever makes any physical contact with people/animals with his teeth.

If contact is made, has any physical injury resulted? If yes, please describe the bite(s) and the incident/circumstances of ALL injury-causing bites:

Does your dog ever show any aggression, or anything that might be perceived as aggression, towards human visitors coming to your property in any situation? If yes, please describe and state how you manage this now:

Does your dog bark repeatedly or persistently (more than a few seconds) in response to anything? If yes, what would trigger this?

Does your dog bark persistently at unfamiliar people arriving at your property?

If Yes, how long would this continue for?

Have you noticed any patterns that relate to any of your dog’s behavioural problems? 

If you have more than one dog, what difference does the presence or absence of the other dog(s) make to the behavioural problem(s)? If you do not know, please try to find this out:

Has a verbal or written complaint regarding your dog’s behaviour ever been made to any official body (eg police, dog warden, RSPCA, local council environmental health dept)? If yes give details:

Please list date or age each problem behaviour was first seen:
Date/Age	Behaviour

(If relevant) when did you first see any signs of aggression towards anyone or anything?

What have you done (if anything) so far to a) correct or b)manage the problem(s):

From inside your home or in your garden, is your dog able to see people, dogs etc passing the property and, if yes, what is his reaction?

If you have sought help from outside sources (including friends, internet/TV advice, one to one trainers, classes, behaviourists) for the problem (s) previously, please detail this below including who you have used, when and for what you saw them, and what programme what was recommended.

Section 3: Supplementary information
Exercise and stimulation:

What type and amount of exercise does your dog have? what proportion of walking is on lead vs off lead? What is the minimum s/he gets in a day? If this has changed, please also describe change: 

Do you ever or have you ever used a pet sitter, dog walker or kennels? 

What equipment (please describe type of lead, what type of attachment and what it is attached to) do you use to walk your dog and what have you used previously? 

Is your dog toy-motivated? Will he play with you? If so, how? What is his favourite toy/game? 

Where do you keep your dog’s toys? Does your dog have free access to all of them? 

Would your dog get excited if you were to get any of his toys out right now? If so, which toy?

Do you think your dog is more motivated by his favourite food or his favourite toy?

Would your dog play “tug” games if invited?

Do you think your dog suffers from problems involving “over-arousal”, poor self-control or having difficulty controlling his response to things?

Does your dog receive any form of mental stimulation on a daily (or near-daily) basis, such as nosework games, training that requires him to think and work things out or use of activity toys to dispense some of his food? 

How many hours sleep do you think your dog gets in the average 24 hour period (day and night added together):

Does your dog ever eat animal faeces? 

Housing:

Where does your dog sleep at night?  		Is this where you intended? 

Where does he/she stay when you go out? 

Is your dog left alone regularly? If so, for how long and how often? 

Does any part of your home (that is accessible to your dog) have hard floors? Please describe: 

Are there any problems when you leave him/her alone – either when you go out, or leave him/her confined to a room while you are elsewhere in the house? What happens? 

If you have more than one dog, what happens if you leave them totally alone, without the other dog(s)? 

Does your dog follow you (or anyone) to the point of this being obsessive? 

Does your dog ever have access to your garden unsupervised?

Has your dog ever been crate trained? If so when and how long was a crate used for?

How does/would your dog react to the following situations:
1.	He was shut in a room completely alone behind a closed door while you are elsewhere in the house?

2.	He was shut in a cage or behind a stairgate in sight of family members?

3.	He was left totally alone in the house?

4.	Family mealtimes or someone eating something

5.	Dog mealtimes

6.	An unfamiliar person coming to the door/house

7.	A familiar person coming to the door/house

8.	In the garden

9.	Travelling in the car:

10.	To noises heard in the house or garden (eg dog barking, door slamming)

Training History:

Have you attended training classes or puppy parties with your dog? How old was the dog at the time? Please describe the class/training: 

How long did you attend for? 

Were there any problems with this? 

Can you remember how you house-trained the dog? Please describe: 

Does your dog walk nicely on a lead? 

Does your dog come when called in all situations? 

How did you teach this? 

Does your dog drop or give objects when asked?  

How did you teach this? 

Miscellaneous

If not already covered in Section 2, has your dog ever shown any signs of fearful, aggressive or otherwise inappropriate behaviour around any of the following? If Yes, please describe:

Familiar dogs:

Unfamiliar dogs:

Other animals:

Unfamiliar adults:

Familiar adults:

Unfamiliar children:

Familiar children:

Vet/groomer:

Post/postman/courier deliveries: 
Passersby to house or garden 

Vehicles or other moving non-living objects: 

Noises:

Anything else?

Does your dog show signs of aggression, anxiety or avoidance to any of the following situations (please state which, what form this takes and whether this is  general or only with specific people).

Handling/grooming:

If disturbed when resting:

If reprimanded:

If trying to take food, toys etc away:

Being cuddled, hugged:

Is your dog allowed on the furniture?  If not, does s/he try and what do you then do? 

If yes, will he/she get off immediately when asked and does s/he ever show any aggression in this situation? 

Does your dog have any “doggy friends”? 

Does your dog ever show signs of possessiveness or aggression over food, toys, bed, owners or other objects?

Is this your first dog as an adult? If no, what breeds/dogs have you owned as adults prior to this dog?

Rehabilitation
How do you rate your family’s commitment to improving your dog’s problems, including the amount of effort and time you are willing to put in and your willingness to change your routines and  ways of doing things? Please be honest!

What would you envisage happening if the behaviour problem persists as it is now, or gets worse? 

Which areas of your dogs behaviour would you ideally like to improve (in order of importance):

What is the single most important thing that you would like to change about your dog’s behaviour?

By returning this questionnaire, you are confirming that you have read the consultation guidelines in full and agree to the information and conditions therein. 

The contents of this form are confidential, and the information received is shared only with the referring vet (and with an attending student if you give your consent to this).