Separation Anxiety

Initial Consultation Questionnaire

Client Information

First name

Last name

Mobile Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Dog Information

Dog's Name

Dog's Age

Dog's Sex

Veterinary Information

Vet Office Name

Vet's Name

Vet's Phone

Vet's Email

I give you permission to contact and discuss health and behavioral concerns with my veterinarian.

Veterinary Behaviorist Office Name (if applicable)

Veterinary Behaviorist's Name (if applicable)

Veterinary Behaviorist's Phone (if applicable)

Veterinary Behaviorist's Email (if applicable)

I give you permission to contact and discuss health and behavioral concerns with my veterinary behaviorist.

Date of Most Recent Vet Exam

Month

Day

Year

Current Medications

Medical History Notes

Household Information

List the names and pronouns of people currently living in your household

List any other pets

Has your household population changed (i.e., addition / loss of people or animals) since the SA began? If so, how?

Has your dog had previous owners?

If yes to previous question, please explain.

Any other information you would like to share?