Dog Behaviour Referral Questionnaire for Pets in Practise

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					   Arrowsmith Behavioural Consultancy
    2 Church Road, Church Lawford, CV23 9EG
             info@gooddog.co.uk
                0845 2600364



 Referral Questionnaire For Owners
 This form will provide me with information
which will help during your consultation. I appreciate that it takes time to complete but these
details are important for safety and accuracy during your behavioural programme. It may help
 for you to save this to your computer and save your changes regularly so that you don’t risk
                     losing your work. Adjust the spaces if you need more.
  When complete, email this back to me prior to your consultation appointment. Thank you

Name:
Address:


Telephone Numbers:
E-mail Address:

Name of Veterinary Surgeon:

Address of Veterinary Surgeon:


Problem Pet(s) Please give details about the pet(s) being referred for consultation

Breed:
Name:
Age Now:
Age Acquired:
Sex:
Neutered? / If Yes, when:

Other Pets Please give details about the other animals living in the home or that have close
contact with the referred pet. Please provide more info about other pets on the back page.

Breed:
Name:
Age Now:
Age Acquired:
Sex:
Neutered?/ When:
Tell me about your family members and friends who have contact with your pet.




Describe your cat’s general character. Does everyone in the family share this opinion?

(There will be a chance to tell me about your cat’s problems and history/routine next.)




Problem Behaviour

Please give details of how and when the problem behaviour you are seeking help for
started. Include as many details of the incidents as possible in chronological order.
Where possible give times of day, place, people and other animals present, injuries
sustained etc. How often does this problem occur? (In the next section you will be
asked about what you have tried to do in order to solve the problem.)

(If your problem involves inappropriate toileting or spraying, please can you also
provide a basic diagram of your home indicating where the problem began, where it
spread to etc.)
Describe what you have tried to do in attempt to cure the problem and what the
results have been. I need to know as much as possible about these methods, even the
ones you just tried once and the length of time you tried them for.




Problem Pets
Acquired from? (Breeder, family home, rescue, other. Please provide whatever details you
have.)


Where were kittens living? (In cattery, In house with family, in outdoor shed/barn, other)



Parentage (Did you meet the parents, is there any family history of problems?)



History from 0 – 1 mths(where lived, socialised with people and other pets, any early
problems including those resolved. What kind of personality did your cat have when he/she
came home)




History from aged 1 to present (where lived, socialised with people and other pets, any early
problems including those resolved)




Problem Pet’s Medical History

Previous

Present / ongoing

Current Medication
Food Details

Diet (to include normal daily diet and titbits)




Problem Pet’s Character (you will have space to describe the problem behaviour in the next
section)

Where does your pet sleep at night?

Where does your pet sleep during the day

Does your cat like playing games with people?

Does your cat like playing games with your other pets?

Does your cat like to play games with toys alone?

What activity would most likely be your cat’s favourite overall?



Handling:

Does your cat like being touched/groomed by owners?




Does your cat allow touching/handling by strangers/vet/groomer?

Describe your pet’s reaction to unfamiliar adults?

Describe your pet’s reaction to unfamiliar children?

Exercise: (State whether your cat has access outdoors/cat pen/within house)



House Rules: Please list any house rules such as access to some areas, not allowed on
sofa/worktops, in bedrooms etc.




This form can be e-mailed back to me on: info@gooddog.co.uk before your appointment
                             Faxed on : 01737 501084
                      Thanks and I look forward to seeing you.

				
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posted:10/3/2012
language:English
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