OVRS - Behavior Consent Form

Oakland Veterinary Referral Services 1400 S. Telegraph Rd, Bloomfield Hills, MI 48302 Theresa L. DePorter, DVM, MRCVS, DECAWBM, DACVB Veterinary Behaviorist
Today's Date

MonthDayYear
Date
Date and time of Consultation (if Scheduled)

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
A Skype account will need to be set up prior to the appointment. Do you have a skype account?

YesNo
What is your skype account Name?
Address

Street Address

Street Address Line 2

CityState

Zip Code
Click here for Canadian Address

Click here for Canadian Address
Address

Street Address

Street Address Line 2

CityProvince

Postal / Zip Code
Home Phone Number
Please enter phone number.
Mobile/Other Phone Number
Please enter phone number.
The Behavior Department will be reaching out by email to schedule your pet's appointment.
What is the best means of contacting you?
Veterinary Clinic
Veterinarian's Name
Clinic Phone Number
Please enter phone number.
Who referred You?
This questionnaire is being completed by:
Have you ever brought in a pet to be seen by ovrs?

YesNo
OVRS department
What was the pet's name, and what last name was it under?

Pet Infomation
Pet's Name
Breed
Date of birth
Age
Color
Weight
Sex:

FemaleMale
Spayed/Neutered?

YesNo
If Yes, When?
Describe Your dog's Personality:
Your Pet’s Early History
Age Obtained:
Date Obtained:
For what reason did you obtain this pet?
Describe where you obtained your dog and/or their previous type of home/s:
(Include the name of breeder/website/advertisement, rescue group/shelter/foster home(s), for how long, with whom, why relinquished and any other details you may think relevant)
Give any information about your dog’s parents or littermates?
(Include whether you met the parents, their behaviour and health status as well as any information about the behaviour of the siblings)

The Home Environment: List each family member in the home (Include yourself, children and/ or frequent visitors):

	Name	Occupation	Family Relationship	Sex	Age	Describe how they get along with the dog
1.
2.
3.
4.
5.
6.
7.

Who else has regular contact with your dog?
(Friends, neighbours, walker, groomer, trainer, day care etc.)

List all other pets in the home:

	Name	Breed	Sex	Neutered/	Spayed?	Age	Describe how they get along with this dog
1.
2.
3.
4.
5.
6.

Describe your previous dog/s:
Describe your home, neighborhood, and yard:
Attach or include a map of your home/yard and provide pictures if this will be useful in fully illustrating your pet’s situation.

Browse Files

Cancelof
Please provide a map of your home/yard and provide pictures if this will be useful in fully illustrating your pet’s situation and email it to the behavior department at behavior@ovrs.com.
Have you moved since acquiring your dog?

YesNo
If Yes, How many times?
How long since the last move?
How did your dog respond to the move?
Has your household (people or animals) changed since acquiring the dog?

YesNo
If yes, please describe

Describe at least 3 specific incidents that stand out to you in detail:
(Include specifics regarding who was present and what actually occurred. If aggression is your pet’s primary problem, describe the details of the incidents here or in the aggression section).
Does your dog settle quickly or does it take them a long time to settle after a situation where they have been aroused or become reactive?
Describe what has been implemented to resolve your dog’s behavior problem/s and the outcome:
What other recommendations have you received about this pet?
From whom?
Veterinarian, Trainer, Breeder, Friends, Family, Social Media, Website/Google, Other
did you follow these recommendations?
what was the outcome?
What books have you read and implemented?

List any drugs, dietary supplements or remedies tried for BEHAVIOR problems:

Please let us know how you feel* about using medications for your pet’s behavior problem:

I wish to use behavior modification alone to improve my pet’s behaviorI wish to use behavior modification alone but will consider using medication if it is recommendedI wish to use a combination of behavior modification and medications to improve my pet’s problemI wish to use a combination of behavior modification & natural supplements to improve my pet’s problemI fully anticipate using medications to improve my pet’s problem
* Your preferences will be considered as the doctor recommends the approach that best fits your pet’s behavior problem.
Describe your goals and expectations for your dog’s behavior:
Describe your goals and expectations for this behavior consultation:
How would a change in your dog’s behavior impact your life?
Describe how you learn best:

Diet and Nutrition

Describe your dog’s meals and feeding routine (including who feeds the dog, where your dog is fed, what you feed and how quickly the food is eaten)
Describe type of treat(s) and when you give them:
What is your dog’s absolute favourite treat?
Does your dog have any food allergies?

YesNo
Medical Information
Describe any current, pre-existing or ongoing medical problems:

List ALL medication/supplements your pet receives currently or frequently (Behavior and Non-Behavior):

Describe laboratory tests:
(INCLUDE BLOOD, URINE, X-RAYS, ETC AND DATE PERFORMED)
When was the last time your dog was seen by a veterinarian?
Please list date and reason

	Normal/appropriate	Decreased	Excessive	New Change?	Describe abnormalities or peculiarities
Thirst
Appetite
Energy/activity
Sleep/rest
Urination frequency
Defecation frequency
Pain threshold
Exercise tolerance
Hearing
Visual acuity
Smell
Vocalization
Self-grooming

	Yes	No	Describe
Does your dog jump up on you without permission?
Does your dog jump on other people without permission?
Does your dog paw at you?
Does your dog paw at other people?
Does your dog lick you?
Does your dog groom, lick or chew himself excessively?
Does your dog lick objects or surfaces?
Does your dog mount people?
Does your dog mount other dogs? Does your dog mount other animals or inanimate objects?
Does your dog ever bark at you?
Does your dog bark at other times?
Does your dog perform any other unusual behaviors?

	Enjoys	Accepts willingly	Accepts reluctantly	Resists	Threatens/aggressive	Cannot attempt	Comments/describe
Nail Trimming
Bathing
Petting
Rubbing belly
Patting head
Hugging/kissing
Being lifted
Approach while eating
Approach while playing with toys
Disturbed while resting

Pet Infomation

	Date (approx)	Who was bitten (name of person or animal)	Relationship (familiar, stranger)	Situation/Context	Describe
1.
2.
3.
4.
5.
6.
7.