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Canine Behavior Recheck Appointment 

Dog Recheck History
Patient's Name
Breed
Age
Date of Birth
Owner's Name
Street Address
City, State, Zip
Primary Phone
Secondary Phone
Has your regular veterinarian changed?
If so, who is it?
What is the primary problem being rechecked?
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What are your goals for this recheck consultation? (Please be specific)
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Behavior Medications
Medication
Dose
List Side Effects
Response to Medication
Medication
Dose
List Side Effects
Response to Medication
Medication
Dose
List Side Effects
Response to Medication
Medication
Dose
List Side Effects
Response to Medication
New Behavioral Problems
Describe the problem
Severity of Problem
Describe the problem
Severity of Problem
Describe the problem
Severity of Problem
Describe the problem
Severity of Problem
Pre-Existing Behavioral Problems
Describe the problem
Improvement of Intensity
Improvement of Frequency
Describe the problem
Improvement of Intensity
Improvement of Frequency
Describe the problem
Improvement of Intensity
Improvement of Frequency
Describe the problem
Improvement of Intensity
Improvement of Frequency
If your pet has developed any new behaviors, either desirable or undesirable, please describe them
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Please give us a detailed description of recent representative events of each current problem. Please include the location, dog’s body postures, any people present, any triggers, your reaction, and the final outcome.
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Have there been any changes in your household since your last appointment?
If so, what has changed?
If you checked "other" please describeyour full name
Does your pet respond differently to one family member than to others? Has this changed since your last visit? If so, please describe:more details
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Current Management
How are you handling specific situations with respect to the problems listed above, e.g., confining your pet when visitors arrive, using window films, getting a pet sitter when you go to work? How does your pet react? Do you feel this is working?more details
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Please indicate below what recommendations you have implemented what what was the outcome:

Recommendationyour full name
Outcomeyour full name
Recommendationyour full name
Outcomeyour full name
Recommendationyour full name
Outcomeyour full name
Recommendationyour full name
Outcomeyour full name

Please indicate below what specific exercises have you worked on, and how have you progressed with them

Exercise
Attempted
Exercise
Attempted
Exercise
Attempted
Are you, any family member, or your pet having difficulty with any parts of your discharge instructions, or are there any recommendations you have been unable to implement? Please explain fully.more details
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Any additional comments about your pet's training?more details
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Number of bites since your last visit?
Number of bites that broke skin?pick one!
Number of bites reported to public health authorities? (ie. local authorities, hospital, humane society, etc.pick one!
Reported to:your full name
Have you recently considered finding another home for this pet?pick one!
Have you recently considered euthanasia? (putting your pet to sleep)pick one!
Has someone recently recommended that you euthanize your pet?pick one!
Has the behavior service helped you with your pet?pick one!
Comments?
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