Behaviour Questionnaire This form is designed to help our team gather important information about your pet's current status for your upcoming visit to our Fear Free clinic! Your pet's name:* Your name:* When did the symptoms first start?*Please list your pet's behaviors you are concerned about in order of severity:*What have you tried so far at home?What are the triggers for your pet's unwanted behaviours?Is your pet crate trained?* Yes No For the most part What kind of positive reinforcements are you using at home when your pet exhibits good behaviour?*What kind of negative reinforcements are you using at home when your pet exhibits unwanted behaviour?*Has your pet been seen for similar condition previously at another hospital? Was anything recommended or prescribed?Where does your pet spend most of his/her day? (inside, outside, in a room, in a kennel, with you)?*Have you noticed any changes in your pet's personality or activity level?*Has your pet had any accidents in the house?* Yes No Is your pet being more independent, less affectionate or more dependent?Are there things your pet is afraid of or does not like? If so, please describe:Has your dog shown any of these signs: coughing, sneezing, itching, diarrhea, vomiting, or lack of appetite? Please describeAny change in grooming or sleeping habits?Any change in food/water consumption?*Itchiness Score*Please rate your pet's itchniness score from 1-10, 1 being not itchy at all, 10 being extremely itchy.12345678910Any change in frequency of urination or defecation?* Yes No Unsure Stool Quality Score*Please rate your pet's stool quality score from 1-5, 1 being profuse diarrhea, 5 being extremely hard.12345Did you bring a stool sample today?* Yes No What, if any, medications (over the counter or prescription) does your pet take or have applied routinely?Please upload a photo of any products, shampoos, medications, ointments or supplements you are using at home for your petMax. file size: 300 MB.What kind of food do you feed your pet? Upload photos of the product: Drop files here or Select files Max. file size: 300 MB. Is your pet fed a grain-free diet? Yes No How often is he/she fed?*When was the last time you have changed your pet's diet?What human food/homemade cooking or treats does your pet get?Does your pet attend grooming/boarding/daycare/dog park facilities?* Yes No Does your pet hunt?* Yes No Does your pet eat feces/drinks outdoor water from wildlife/other pets/its own?* Yes No Was your pet living in or traveling with you to heartworm/tick endemic area in the last 12 months? (States, south west/Northern Ontario)?* Yes No Is your pet on heartworm prevention? Please also upload any photos of the products your pet is on. Drop files here or Select files Max. file size: 300 MB. Do you have any doses leftover from last year?* Yes No Is your pet on flea/tick prevention currently?* Yes No When was approximate last time you found ticks on your pets, if any? (Date) Is your pet microchipped?* Yes No Has your pet bitten any person in the last 10 days which broke the skin?* Yes No Please list any questions/problems/concerns for Dr. Jinni that you would like addressed:Does anyone in your household have a peanut allergy?* Yes No Δ