Thank you for choosing the behavior department here at Hickory. We are very excited to meet your pet and help you both on your way to a better relationship. Please fill out the below information about your pet to help us better understand your situation. The form will save automatically to the computer you are currently using so you can come back later to work on it, if needed. If you have any questions give us a call 610.828.3054. Appointments will not be made until the paperwork is fully filled out and submitted.

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Canine Initial Behavior Appointment 

Dog History
Patient's Name
Breed
Age
Coat Color
Date of Birth
Owner/ Co-Owner's Name
Street Address
City, State, Zip
Primary Phone
Secondary Phone
Emergency Phone
Regular Veterinarian
How did you hear about us?
Household Information
People Living in Household
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
If there are more than four people in the house please add them here.more details
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Other People in Regular Contact with Pet (Petsitter, housekeeper, friends, etc.)
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
If there are more than four people in regular contact, please add them here.more details
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Other Pets in Household (In order of when they came into household)
Name
Species / Breed
Current Age
Age Obtained
Name
Species / Breed
Current Age
Age Obtained
Name
Species / Breed
Current Age
Age Obtained
Name
Species / Breed
Current Age
Age Obtained
If there are more pets please add them here:more details
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Type of House
How long have you lived in this house?
Since adoption, how many houses have you and your dog lived in?
Do you have a yard?
If yes, how big is your yard
Is the yard fenced?
Approximate fenced area
Types of Fence
Height?
Acquisition Information
How long have you owned this dog?
How old was the dog when acquired?
Where did you obtain this dog?
Behaviors of dogs parents/ litter mates (If known):
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Describe previous homes (If known):
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If obtained from a shelter/rescue, describe the information you were given about dogs behavior/ experiences before adoption (including foster homes):
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Why did you choose this breed of dog?
Why did you choose this individual dog?
Neutering Information
Is this dog neutered/ spayed?
If yes, at what age?
Reason for neutering/ spaying?
Current existing behavior problems (list problems that dog had before neuter that you hoped to correct with surgery)
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Did you notice any changes after neutering/spaying?
Please Describe
If not neutered/spayed, reasons for not neutering/spaying:
Medical History
Current Weight
Vaccinations
Date of most recent rabies vaccine:
List of major illnesses/ surgeries (please be sure to include dates):more details
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Please list all medications/ treatments your dog is CURRENTLY receiving, including heartworm, flea/ tick preventative/ collars, dietary supplements, herbal/homeopathic treatments:

Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Daily Activities/ Routine

Meals/ Types of Food

Dry (Brand)your full name
% of Dietyour full name
Canned (Brand)your full name
% of Dietyour full name
Rawyour full name
% of Dietyour full name
People Food
% of Dietyour full name
Other
If you feed a special diet (hypoallergenic, grain free etc.) why?your full name
Eating Habits (Check all that apply)
Feeding (Check all that apply)
Where does your dog sleep at night?
Where does your dog sleep during the day?your full name
If disturbed when sleeping, what is your dogs reaction?
Have you made any changes to where your dog sleeps because of their reactions to being disturbed?
If you answered yes, please describe:your full name

Exercise

Does your pet get regular leash walks?
If you answered no, why?
If you answered yes, who takes the dog for leash walks?
How Often?your full name
How long are the walks?your full name
Location (ie around neighborhood, in town, park etc)your full name
What do you use to walk the dog? (Check all that apply)pick one!
How is your dog on a leash?
Does your dog get off leash exercise?
If you answered yes, who takes the dog for off leash exercise?
How Often?your full name
For how long?your full name
Location (ie. Trails, Dog Parks, Beaches, Yard)your full name
Does your dog play with toys?pick one!
What are your dogs favorite toys? (Check all that apply)pick one!
How does your dog play with toys? (Check all that apply)
How often does your dog play with toys?pick one!
How often does your dog play with people?pick one!
How often does your dog play with dogs?pick one!

Living Spaces/ Being Left Alone:

Where does your dog spend most of their time when people are home?pick one!
Where does your dog spend most of their time when people are NOT home?pick one!
How long is your dog left alone on an average day?your full name
When is your dog left alone? (ie. 8:00am- 5:00pm)your full name
What is your dog's reaction to being left alone? (Check all that apply)
If there will be or have recently been any major chages to the daily routine (ie. vacations, owner who travels for business, etc.) please describe.more details
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Training
Has your dog had any training?pick one!
What type of training?pick one!
At what ages did your dog take each classmore details
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Names of Instructors/ Schools
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What training techniques have you used?pick one!
Who in the household trained the dog?your full name
What commands does your dog know?your full name
Has your dog won any titles (ie. agility, obedience, CGC)?pick one!
If you answered yes, list them:your full name
Did your dog enjoy training?pick one!
How well does your dog obey commands WITHOUT distraction?
How well does your dog obey commands WITH distraction?

How does your dog react to the following:

Unfamiliar people at door to housepick one!
Unfamiliar people in homepick one!
Unfamiliar people, away from home, while on-leashpick one!
Unfamiliar people away from home while off leashpick one!
People on bicycles, roller blades, etc.pick one!
Joggers (adult)pick one!
Cars/ Trucks going by while on-leashpick one!
Babiespick one!
Childrenpick one!
Unfamiliar dogs, when your dog is on-leashpick one!
Unfamiliar dogs while your dog is off leashpick one!
Squirrels/ Cats/ Small Animalspick one!
Dog in yard- person passespick one!
Veterinarian's Officepick one!
Stranger approaching car when dog is insidepick one!
Thunderpick one!
Loud Noisespick one!

How does your dog react to a family member doing the following:

Walk by food while dog eats regular mealpick one!
Reach for or take food dish while dog eats regular mealpick one!
Walk by while dog eats more delicious foodpick one!
Reach for/ take away non-edible toy (ie. ball, stuffed animal)pick one!
Reach for/ Take away edible bone/ rawhidepick one!
Take away stolen non-food item (ie. socks)pick one!
Take away stolen food item (including dirty tissues, paper towels, food wrappers)pick one!
Reach for dropped food at same time as dogpick one!
Reach over head/pet on top of headpick one!
Pet on other parts of bodypick one!
Brushpick one!
Bathepick one!
Pick dog uppick one!
Put on/ off collarpick one!
Put on/off leashpick one!
Disturb while sleepingpick one!
Move while on furniturepick one!
Dog is sitting with one family member and another family member approachespick one!
Hold back when excited (ie. from running out doog) NOT WHEN AGGRESSIVE)pick one!
Hold back when aggressive (ie. barking at another dog)pick one!
Verbal reprimandpick one!
Leash correctionpick one!
Physical reprimandpick one!
Staring at dogpick one!

How does dog react to a dog in the household (if you dog doesnt regularly spend time with another dog you dont need to fill out):

Around regular foodpick one!
Around rawhidespick one!
Around Treatspick one!
Around toyspick one!
Around favorite peoplepick one!
While on walks togetherpick one!
During playpick one!
Has your dog ever bitten a PERSON?pick one!
If you answered yes, describe IN DETAIL when the bite happened (approximate date is ok), who was bitten, what the circumstances of the bite were. Please answer separately for each bite.more details
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How bad was the worst bite your dog ever gave to a person (check all that apply):pick one!
Have any bites been reported to Animal Control or other authorities?pick one!
Have any victims threatened/ taken legal action because of an aggressive incident?pick one!
Primary Behavior Problem

Please fill out this section in detail, it will allow us to spend more time during the appointment discussing treatments instead of going over your dog's history:

What is the one main behavior problem you wish to address?more details
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Describe the very first incident of this problem.

Include the following in your description: Where the incident occured, who else (human/animal) was present, what happened just before the incident, how everyone present reacted. If you noticed any changes in your dog's body language or facial expression before, during or after the incidents please describe.

Try to remember the earliest occurence of the problem, even if it wasn't as serious as it is now. For example, if your dog is aggressive to people, describe the first time she growled or barked at someone, not the first bite. Or if your dog has problems being left home alone, describe the first time he/she whined and cried when you left, not just the first time he ripped up the carpet.

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Date of first incident and dog's age at the time (approximate date/ age is ok.your full name
Describe per instructions above most recent incident:more details
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Date of most recent incident:your full name
Describe per instructions above at least one other incident you feel illistrates the problem behavior (if you would like to describe other incidents, that's great!):more details
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Date of Incident(s)your full name

Frequency of Primary Behavior Problem:

How frequently does this behavior occur?pick one!
Is the frequency...pick one!
What percent of the time that your dog is in a potentially problematic situation does the problem behavior occur?pick one!

What have you tried to do to correct this behavior problem and how did your dog respond?

Training (example- yelled at him when he jumped on visitors. He started to growl):
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Management (Example- put him in the bedroom when people came over. He slept):
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Medications (Tried CBD, no change):
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How serious do you and other members of the household find this problem?more details
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Has anyone suggested that you euthanize or rehome this dog because of this problem (this is not a recommendation; we just want to know what has been suggested)?pick one!
Have you ever considered euthanasia or rehoming your dog because of this problem?pick one!
List other problem behaviors in order of importance to you.more details
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Do we have permission to post pictures on our social media?
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