Please Complete Your Separation Anxiety Questionnaire

Separation Anxiety Questionnaire

Instructions: Please fill out this form as thoroughly as possible. Then use the Print to PDF feature to save your answers and email the completed form.

Note: Please complete the New Client Intake Form in addition to this form. This questionnaire will help me better understand your dog, your situation, and develop a behavior modification program that will improve your dog’s behavior.

Overview

Before you acquired your dog, did he/she have a history of separation anxiety or any kind of destructive behaviors? *

Age of your dog when behavior began: *

How long is your dog typically left alone during the day?

How long after you’ve been gone does it take for your dog to begin displaying nuisance behaviors?

Describe your dog’s main sources of exercise and the exercise’s frequency:

Veterinary Information

Date of your dog’s last vet visit:

MM-DD-YYYY

Is your vet aware of your dog’s behavior? *

List of all medications your dog is taking or has taken in the last 12 months: *

Attempted Solutions

What have you done to try to improve your dog’s behavior or address this situation? *

Have you attempted to use any calming sprays? If so, which ones: *

Have you attempted to use no-bark collars or bark deterrents of any kind? If so, which ones: *

Complaints

Has your dog’s behavior caused family to complain? *

Has your dog’s behavior caused neighbors to complain? *

If you’re renting, has your landlord expressed concerns about your dog’s behavior? *

Environmental Changes

How many times has your dog been rehomed? *

Has the dog changed residence recently?

If so, please explain when and where the dog came from and moved to:

Have you changed where your dog stays while you’re away recently? *

Has your or your family’s schedule changed recently? *

Has construction started within one mile of the home recently?

Has a family member joined or left the household recently? *

Has your dog’s diet changed recently? *

Symptoms

Has your dog displayed any of these symptoms in your absence?

Urinating or defecating
Excessive barking or howling
Destructive chewing or digging
Escaping crate or yard
Pacing or OCD behaviors
Consume own excrement
Other:

Write the frequecy in the box.

Was your dog potty trained before this behavior began? *

Can your dog look out of any windows while you’re away? *

What kind of toys does your dog have access to while you’re away?

Is your dog content to be left alone with anyone or is he/she hyper-attached to a single person? *

How quickly are you hoping to have this behavior changed? *

Do you have neighbors or family members that could care for your dog in your absence? If not, can you work with a local dog day care to care for your dog while you’re away? *