Problem Diagnosis and Corrections Service Form

Please answer the following questions, then  e-mail, fax or mail them to us.

BehavioRx
P.O. Box 1658
Grants Pass, OR 97528
Phone: (541) 476-5775
Fax: (541) 476-5523
Email: billcamp@webtrail.com

BehavioRx Case Record

Date:			
Your Name:		
E-mail address:		
Telephone:		
Street Address:		
City:			
State:			
Zip code:		
Country:		

Method of Payment

Visa
Mastercard
Check

I'll call 541-476-4775, or fax 541-476-5523 with credit card information.              

Environmental Information
Family data:

Number of adults in household (Please list with information regarding 
marital status, family relation, such as Mother-in-law, aunt, uncle,
cousin, etc., in case you have other than your immediate family 
living in the home. Let us know if there are special circumstances, 
such as physical disabilities,etc., which may be pertinent to the
problem.)


Number of Children, their sex & ages


Other pets (List by species,cat, bird, gerbil, etc., breed, age, age 
obtained, sex, whether or not neutered or spayed , where obtained.)


Family schedule:
(Let us know the general daily acitvitities and schedule of people).


Pet Information
Name:	
Breed:	
Age:	
Sex:	
Let us know if the dog has been spayed or neutered. 
if so, please state the age it was done. 
Spayed/Neutered      Age: 
What age was the dog when you got it?	 
Who and where did you get it from
(pet shop, breeder, neighbor, etc.)	
How much did you pay for the dog?	
If you saw it in the litter, 
please describe where it was born, 
(indoor, outdoor, etc.) 		
Describe the pup's litter behavior, if you saw it.


Briefly tell us how you housetrained, or are housetraining.
(Include what you do if you find a mess, etc.)


What other training have you done? Please include formal obedience and/or
home-training, what sort of equipment was used (types of collars, leashes,
halters, food tidbit training, crate training, electronic devices, etc.)


Where does the dog sleep?		
When left alone, 
where does the dog stay?		
What food do you feed?			
How much?				
How many times a day is the dog fed?	
Who feeds?				
Are food tidbits given?			Yes/No
How often is the dog bathed?		
Who bathes the dog?			
How often is the dog brushed?		
Who brushes? 				
If you and others play with the dog, please tell us how you
and/or others play?


How often do you or others play with the dog?


Health history
What was the date of the 
last Veterinary appointment?		
What was the purpose and outcome
 of that appointment?			
Briefly describe the dog's veterinary health history. (Such as
wormings, illness, medications., etc.)


We may need to discuss certain problems with your veterinarian. Many
behavior problems have strong relationships with health problems
and treatments.
What is your veterinarians name?	
Veteriarian's phone number.		


Behavior Problem(s)
How old was the dog when the
behavior first occured?			
Give us a "word picture" of the problem. Let us know what the dog 
actually does. How have you reacted to the problem behavior? We 
need another word picture for this, too.


What is the most harsh treatment your dog has ever received?
(Include physical punishment, being put out, who did the punishing, etc.)


If you've had special trainers or consultations about the problem, 
please describe what was done.


Additional comments you think may be helpful, 
even if it's just a hunch. Often something that may not seem 
too important can be most helpful.

Thanks for your interest in solving your dog's behavior problem. Our correction recommendations involve no physical punishment, or even scolding. Totally positive steps lead to a closer, more satisfying relationship with the dog, which is the foundation for successful corrections.


Bill Campbell