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Online Pharmacy
Learn more about SNOUT Wellness plans
Mon, Tue, Thu:
8:00am – 6:00pm
Fri:
8:00am – 5:00pm
1st & 3rd Sat each month:
8:00am – 1:00pm
Wed & Sun:
Closed
1071 Old Henderson Rd.,
Columbus, OH 43220
[email protected]
(614) 451-4772
Request Appointment
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Mon, Tue, Thu:
8:00am – 6:00pm
Fri:
8:00am – 5:00pm
1st & 3rd Sat each month:
8:00am – 1:00pm
Wed & Sun:
Closed
1071 Old Henderson Rd.,
Columbus, OH 43220
[email protected]
(614) 451-4772
Search
Request Appointment
Canine Behavior Form
Behavior Questions For Dogs
Patient Info
Pet’s name
Breed
Date of Birth (approx age if N/A):
Sex
Male
Female
Spayed/Neutered
Yes
No
Owner Info
First Name
*
Last Name
*
Address
Address
Address 2
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
Preferred Phone
Email
*
Additional Contacts
Name
Preferred Phone
Email
General Health
(If any have changed before or since Behaviors started describe)
Eating
Drinking
Current Diet/Frequency and Amount Fed
Defecation
Urination
Energy/Mobility
Vomiting?
Yes
No
If yes describe
Coughing/Sneezing?
Yes
No
If yes describe
Pain/Discomfort?
Yes
No
If yes describe
Current or Ongoing Health concerns
Current Medications (dosage/Frequency/form):
Behavioral Health
Describe the Behavior Issue(s)
Dates and Details of problematic incidents/occurrences
Where does the Behavior Occur?
Frequency of Behavior
When did Behavior first start?
Any Recent changes/ Has theBehavior been consistent?
Home Environment: Please list all people (including yourself) and other pets in the household
Name
Age
Species
Average daily hours in home
Quality of relationship with Pet
Poor
Neutral
Good
Great
Add Another?
Yes
No
Name
Age
Species
Average daily hours in home
Quality of relationship with Pet
Poor
Neutral
Good
Great
Add Another?
Yes
No
Name
Age
Species
Species
Average daily hours in home
Quality of relationship with Pet
Poor
Neutral
Good
Great
What is your Dog’s response to Visitors?
Frequent Visitors
Occasional Visitors
Repair/Delivery Persons
What does your pet tend to resource guard (people, places things and/or food)
Who or what does your pet typically guard against (People either general or specific, or pets)
Training History
Has your dog ever attended a training class (if so please give details)
Has a Trainer ever worked with your dog (if so give details)
What Training methods have been used in the past? (i.e. clicker training, verbal corrections, etc)
What Behavior management products have been used (puzzle toys/feeders, easy lead harness, basket muzzle, increased physical or mental stimulation)
Has your pet worked with a veterinarian before? Who/what was diagnosed/what were treatments?
Has your pet been on medications for their behavior?
Misc.
What are your current Goals for your pet (comfort around strangers, sport/agility courses, companionship etc.)
What is the timeline you are working under (ex. Pet is staying with sitter they do not trust in 2 months)
Any comments/concerns would you like NWAH staff to know?
