Client Name*

First

Last

Name*

This section of the history form is to be completed only if your dog is showing any repetitive, ritualistic behaviors that you find troublesome or about which you are concerned. If your dog is not doing this, you do not have to complete this form.

The first section focuses on a description and categorization of your dog’s behavior(s)
The second section focuses on patterns of behaviors. Please indicate the appropriate answer (YES/NO/UNCERTAIN) for each question.

1. Which of the following categories below fits your dog's behavior? Tick as many categories that apply to the dog's behavior. Then tick the best description that relates to the selected behavior.

Grooming
Hallucinatory
Consumptive
Locomotory
Vocalization

Grooming

Chewing self
Biting self
Licking self
Plucking hair from self
Trimming hair on self
Sucking self
Continuously doing any of these to another individual
Other

Other

Hallucinatory

Staring and attending to things that are not there
Tracking things that are not there
Pouncing on or attacking things that are not there
Other, please explain:

Other, please explain

Consumptive

Consuming rocks
Consuming dirt or soil
Consuming other objects
Licking or gulping air
Eating, licking, sucking, or chewing wool or fabric , rugs, furniture, et cetera
Other:

Other

Locomotory

Circling/ spinning
Tail-chasing
Freezing
Other:

Other

Vocalization

Rhythmic barking
Howling
Growling
Other:

Other

2. Was there a change in the household or an event associated with the development of the behavior?

Yes
No
Uncertain

Comment

3. Is there any time of day when the behavior seems more or less intense?

Yes
No
Uncertain

Comment

4. Is there a person or another pet in the presence of whom the behavior seems more intense?

Yes
No
Uncertain

Comment

5. Does the dog respond to its name or seem aware of its surroundings while in the midst of the behavior?

Yes
No
Uncertain

Comment

6. Is the dog aware that you are calling him/her?

Yes
No
Uncertain

Comment

7. Can you convince the dog to stop the behavior by calling him/her?

Yes
No
Uncertain

Comment

8. Can you convince the dog to stop the behavior by using physical restraint?

Yes
No
Uncertain

Comment

9. Is there a location in which the dog prefers to perform the behavior?

Yes
No
Uncertain

Comment

10. Does any event or behavior routinely occur immediately before the behavior begins?

Yes
No
Uncertain

Comment

11. Does any event or behavior routinely occur immediately after the behavior ceases?

Yes
No
Uncertain

Comment

12. Has the dog's general behavior changed in any way since the onset of the atypical behavior (i.e., the dog is more or less aloof, aggressive, withdrawn, playful, et cetera)?

Yes
No
Uncertain

Comment

13. Has the dog's diet recently been changed?

Yes
No
Uncertain

Comment

14. Did anyone else in the dog's family exhibit these or similar behaviors?

Yes
No
Uncertain

Comment

15. List the kinds of things (i.e., noises, treats, toys), if any, that will interrupt the behavior once it has started.

16. For ingestion, list what types of objects are consumed. Be as specific as possible-what type of rug or sweater fabric?

Stereotypical and Ritualistic Behavior History

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