Canine Behaviour Questionnaire

Canine Behaviour Questionnaire

Completing this form is part of your assessment
Thank you for being here to complete your form, this is the first step in making changes.

BOOKING POINT: This can be accessed once you have completed this form.

VIP: Please ensure you read this entire section before proceeding
Please ensure you allow ample time to complete this form. This is an extensive document to gather as much data as possible to help you succeed.

This form is best to be completed on a computer or tablet, you will struggle on a phone.

Please remember to save your form to ensure you do not lose your answers. As you save you will be emailed, please check your spam folder.

You can also then return to complete it. The save button is at points throughout and at the bottom of the form.

Obtaining the following information before consultation allows more time during your first appointment to dedicate attention to you. Please ensure this document, along with the veterinary referral form, are completed and signed so your assessment can proceed.

Please fill in each question as accurately and honestly as possible, there are no right or wrong answers. The more information you provide here, the less time is needed to clarify answers on assessment.

Once your form is submitted you will be signposted to book your behaviour programme. This form will not be read until you have secured your programme and behaviour assessment appointment.

Rescue Dogs from Abroad: You will need to provide proof of a negative Brucella test prior to attending any in-person appointments. If you are unsure please stop here and check before proceeding.

If you have any issues: this usually relates to the browser you are using and if you are doing it on a mobile phone. If you have difficulties please WhatsApp on 07841040171 during business hours for a workaround.
Once this form is complete it will not be read until you have purchased a programme and booked your behaviour assessment appointment.*

I understand and will book my programme
I understand I must request my veterinary surgeon complete and directly send a referral form*

I understand and have initiated this form
The current appointment schedule for behaviour assessments are as follows. Please tick if you will be selecting In-Person or Online to indicate you understand.*

In-Person: Tue or Fri 10.20am (occasionally 9.30am) (subject to change/availability)Online: Fri at 1pm (sometimes Tue is also available)
PRIVACY POLICY
Your data is collected, stored and used in line with the General Data Protection Regulation (GDPR).

The personal data you share with us allows us to visit you for home visits, communicate educational resources, prepare for group or private sessions and contact you when we need to regarding the service you have booked (especially in the event of emergency). It also allows us to ensure you are recieve the correct service.

A full copy of our privacy policy can be found here.

Consent
By consenting to this privacy policy notice you are giving us permission to process your personal data specifically for the identified purposes. Consent is required for Katey Aldred to process your personal data, but it must be explicitly given. Where we are asking you for sensitive personal data we will always tell you why and how the information will be used.

You may withdraw consent at any time by contacting us to inform us, all data held will immediately be erased.
Privacy & Consent*

I give consent for my details to be collected and stored and wish to proceed with my behaviour programmeI do not consent for my details to be collected and stored wish to terminate my behaviour programme (please just close this window if you select this option and contact us to discuss booking).

Section One: Owner Information
Section One: Owner Information
TECH CHECK:

- Complete with a tablet or computer

- Ensure you have a stable internet connection

- Ensure you enter the correct email address. Each time you SAVE you will be provided with a pop-up window with a link (copy and keep this safe) and an email. If the email does not arrive please check your spam folder and allow up to 30-minutes for this to push through.

Complete this section, click SAVE then head to your emails to ensure you receive the link to complete the form.

In case of an issue send a text or WhatsApp to Katey on 07841040171 in the first instance.

Issues are usually related to the browser and device you are using please do not use a phone.
Your Name*

First NameLast Name
Your E-mail*
Mobile Number*

Area CodePhone Number
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postcode*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family living in the home: name/age/relationship*
Extended family with regular contact: name/age/relationship*
Other pets: species/name/age & type of relationship*
Please write N/A if no other pets
Do you or any family members caring for your dog have any medical, or learning issues you feel the assessor should be aware of (deafness, anxiety, learning difficulties for example)?*
Please write N/A if no other pets

Section Two: Dog's Information
Section Two: Dog's Information
Name & Breed*

NameBreed
Please upload a favourite photo of your dog*

Browse Files

Cancelof
D.O.B & Age*

D.O.BAge
Age obtained*
Origin of your dog*

Private breederPrivate rescueRescue centreRescued from abroad
Rescues from abroad: Has your dog been tested for Brucella? (you will need to provide proof of a negative test result to be seen in person).*

YesNoNot sureNot a rescue from abroad
Decision for choosing this breed or individual?*
Gender and neutered status*

Female EntireFemale NeuteredMale EntireMale Neutered
If neutered, reason for neutering:*
Write N/A if entire
Previous Owners?*

YesNo
Home many previous homes? (if answered yes above)*
Write N/A if not had previous owners
Rehome reason*
Write N/A if not had previous owners
Briefly describe your dog’s personality when not experiencing the issue (confident, timid etc) PLEASE DO NOT WRITE ABOUT THE PROBLEM BEHAVIOUR HERE THERE IS ROOM FOR THIS IN SECTION SEVEN.*
Describe interactions with pets:*
N/A if no other pets
Describe interactions with family:*
Do you use a crate? If yes, dog’s reaction:*
Dog’s favourite sleeping location:*

Daily Interactions - please select the best descriptor for each activity*

	Not every day	Up to 30 minutes	30-60 minutes	1-2 hours	Over 2 hours	Only at weekends	Never
Walk on lead
Walk off lead
Training
Grooming
Play
Affection
Play with other animals
Other

Who interacts the most with your dog?*

Methods & Training History Please put select any that you use/have used:*

	Currently using	Have used in the past	Never Used
Citrus collar
Reward based methods
Praise
Telling off
Harness
Head collar
Pack leader
Water spray
Bottle with stones
Correction
Loud noise
Treats
Time out
Cool down area
Clicker
Normal flat collar
Normal dog lead
Metal lead
Retractable lead
Half check collar
Full check collar
Prong collar
Slip lead
Long line
Clapping
Poking
Other (please write below)

Other method (if not listed above):
Training History (please tick all that apply):*

My dog is attending some form of training (121 /classes /workshops)?My dog has attended some form of training in the past?My dog hasn't attended any form of trainingI have had behaviour help/advise from another professional
If you have had some form of training or behaviour help please detail: trainer/behaviourist name, company name, how many sessions, what you had help with*
Write N/A if this does not apply

What training exercises can your dog do to what standard?*

	Not trained	Sometimes	Most of the time	All of the time, in any location
Sit
Stay
Down
Come
Wait
Heel
Leave
Fetch
Settle
Bed
Other (write below)

Other exercise:*
What do you feel is your dogs learning ability?*
What is your dog's favourite reward?*
Who is your dog most responsive to?*
What method is your dog most responsive to?*
Health & Medical
Veterinary Practice*

Name

Street Address

CityState / Province

Postal / Zip Code
Veterinary Surgeons Name*

First NameLast Name
Practice Phone Number*

Area CodePhone Number
Practice Email*
example@example.com
Previous or Current Conditions:*
Describe and include any tests or procedures
Previous or Current Medications:*
Describe, name, dosage, duration
How does your dog react to examinations?*
Diet Name*
Please write the SPECIFIC brand name/s for the diet/s you use
Mealtimes *

Appetite & Elmination *

	Normal	Decreased	Increased
Drinking
Appetite
Defecation
Urination

Section Four: Reaction Information
Section Four: Reaction Information & multiple choice
Please download this multiple-choice form, complete it and upload it below

WORD VERSION - click here

PDF VERSION - click here
Upload Section Four *

Browse Files
Upload your completed form here Cancelof

Section Five: Toilet Habits (optional)
Section Five: Toilet Habits

Skip this section if you have no issues with toileting
Main toilet location?
Your reaction when it is in the wrong place:
When does your dog toilet in the wrong place?

Please select any/all that apply for toileting in the wrong place

	Daily	Couple of times per week	Couple times per month	Where sleeping	In crate if confined	Anywhere
Urinate
Deficate

Please select any/all that apply for toileting in the wrong place

	When excited	When frightened	During sleep	When approached	When strangers approach	When dogs approach	During veterinary examinations
Urinate
Deficate

Anything else to add?

Section Six: Separation Information (optional)
Section Six: Separation Information

Skip this section if you have no issues with separation behaviour
Please read: This section is to gather information on separation related behaviours. If your dog has never displayed any issues with this you can skip this section.
How long is your dog left on average each day, what time?
Where is your dog left and how do they act?
How does your dog behave as you prepare to leave?
If your dog is ever left with a friend, kennel, or relative, how do they react?
If your dog is ever left outside please state how they react?
What problem behaviour is experienced when your dog is left?
Does your dog behave differently for different people?
Please upload a floor plan of your house with key areas your dog is left in or that are problematic. A rough sketch is fine, it doesn't need to be fancy.

Browse Files

Cancelof

Section Seven: Behaviour Problem
Section Seven: Behaviour Problem

This section is for more details on the answers you have already provided above
MAIN ISSUE:*
What is the MAIN issue you are seeking help with
When did you first notice the problem/ what age?*
How does this impact you? What are your concerns?*
Frequency: how often do you experience the problem, how long does it last for?*
Cause: do you think anything caused the issue/s, or were there any significant household changes at the time?*
Dogs Reaction: What triggers the problem, can you interrupt your dog? How does your dog behave afterwards?*
Body Language: what type of body language have you noticed during this incidents?*
ie fur raised, ears up, tail position, trying to run away etc?
Family reactions: how do you deal with the problem/s, what have you tried? Did anything help?*
Please give a detailed description of the last incident:*
List any drugs, supplements, or diets tried:*

Severity of the problem on a scale of 1 – 10 (10 being the worst):*

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

SECOND ISSUE:*
What is the SECOND issue you are seeking help with. If there is no second issue just put N/A in each box
When did you first notice the problem/ what age?*
How does this impact you? What are your concerns?*
Frequency: how often do you experience the problem, how long does it last for?*
Cause: do you think anything caused the issue/s, or were there any significant household changes at the time?*
Dogs Reaction: What triggers the problem, can you interrupt your dog? How does your dog behave afterwards?*
Body Language: what type of body language have you noticed during this incidents?*
ie fur raised, ears up, tail position, trying to run away etc?
Family reactions: how do you deal with the problem/s, what have you tried? Did anything help?*
Please give a detailed description of the last incident:*
List any drugs, supplements, or diets tried:*

Severity of the problem on a scale of 1 – 10 (10 being the worst):*

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Please give a detailed description of the last incident:*
THIRD ISSUE:
Is there a THIRD issue you are seeking help with.
When did you first notice the problem/ what age?
How does this impact you? What are your concerns?
Frequency: how often do you experience the problem, how long does it last for?
Cause: do you think anything caused the issue/s, or were there any significant household changes at the time?
Dogs Reaction: What triggers the problem, can you interrupt your dog? How does your dog behave afterwards?
Body Language: what type of body language have you noticed during this incidents?
ie fur raised, ears up, tail position, trying to run away etc?
Family reactions: how do you deal with the problem/s, what have you tried? Did anything help?
List any drugs, supplements, or diets tried:

Severity of the problem on a scale of 1 – 10 (10 being the worst):

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Do you have more than THREE issues? If you do please detail them in a separate document following the questions in the order they are above and attach it as a file.

Browse Files
Tell us about a fourth or more issues. Cancelof
Section Eight: Additional Information

Have we missed anything?
Do you have any conditions we need to be aware of that need special consideration during your sessions? (anxiety, learning difficulties, physical impairment etc). This information ensures we tailor our service to meet your needs. *
Write N/A if nothing else to mention
Do you have any previous history or trauma with dog's that might need consideration (such as having a previous dog with behaviour issues). This might help us understand any concerns you have with more depth *
Write N/A if nothing else to mention
Please upload any other supporting documents you feel are relevant and want to share.

Browse Files

Cancelof
Section Nine: Signature Required
I understand that submission of this form does not mean I have secured an appointment and will follow the steps to complete this.*

Yes
Appointments are subject to availability and might change between your inquiry and your completion of this process. You will unlock access to the diary once you have purchased your behaviour programme. Once purchased this will trigger automated emails for you to book your own appointments in the diary.

In submitting your questionnaire and proceeding with a programme you agree to the full terms and conditions which can be viewed here.
I agree to the above points.*

Yes
I confirm I have completed this form to the best of my knowledge and agree to the terms and conditions of service as per booking. Full terms and conditions, and privacy policy are available to view on the website here.

Please do contact me if your situation changes. I look forward to meeting you and your dog.
PLEASE NOTE: When you click on this field to complete your browser might push the box further up the page. Please scroll up if you click to complete but cannot view it and it will be there.

DATE: Date* First Name* Last Name*
Signature*

Clear
Should be Empty:

Canine Behaviour Questionnaire

Section One: Owner Information

Section Two: Dog's Information

Health & Medical

Section Three: Aggression Screen

Section Four: Reaction Information & multiple choice

Section Five: Toilet Habits

Section Six: Separation Information

Section Seven: Behaviour Problem

Section Eight: Additional Information

Section Nine: Signature Required