Canine Pre-Consultation Questionnaire

Below is some information I’d like you to collect, if possible, before our consultation so we can make the most of our time together. These questions (everything between the two lines below) can be easily copied into an email or DOC file and sent to me with your responses. If you would prefer to have the form sent to you directly, please email mm@mmilani.com to request this.

If you have more than one dog, please supply the information for each animal.

Try to get input from others who live with the dog as well as those who see the dog periodically. Not only may dogs relate differently to different people, we’re often so close to our dogs that we miss things that others can see.

Information about the consultation—the fee, what it includes, setting up an appointment, etc.—is at the bottom of the page. If you have any questions about any of this, please email me at mm@mmilani.com.

I look forward to helping you and your dog(s).

Myrna Milani
Myrna Milani, BS, DVM
Tipping Point Animal Behavioral Consulting Services
Charlestown, NH


Consultation information:

Your Name:
Address:

Phone:
Email:
Referred by (if applicable):
Your dog’s name:
– Age:
– Breed:
– Sex:
– Weight:

  1. Where, when, and how you got your pet.
    If you know any information about your dog’s littermates, including number of males and females in the litter, and/or about your dog’s parents, that would also be helpful.)
  2. If and when your dog was spayed or neutered.
  3. Where does your dog eliminate, i.e. pee and poop? Does your dog lift his or her leg when urinating? If so, where and when does this occur?
  4. Basic information (age, sex, species, breed) of other animals in the household or with whom your dog routinely interacts.
  5. Basic information (age, sex) of other people in the household or with whom your dog routinely interacts.
  6. An overview of your dog’s pertinent medical history
  7. What your dog eats and how, i.e. gulps, disinterested, snacks, leery of /aggressive toward others when eating.
  8. How does your dog act:
    • In the car.
    • When you’re gone, i.e. is there evidence that your pet is distressed, such as chewed objects, house-soiling, vomiting or drooling?
    • When you and other family members come home. (Note any differences that occur)
    • When visitors arrive. (Note any differences toward men, women, adults and kids, little boys vs. little girls.)
    • Toward other dogs. (Note any differences toward males and females, unneutered and neutered.)
  9. Does your dog play? If so, how?
  10. Does your dog display any sexual behaviors such as mounting, masturbating, or getting between you and others when you are displaying affection toward each other?
  11. Finally, list the problem displays in chronological order from the first to most recent incident.
    Jot down notes about the circumstances surrounding each event and how you and/or others responded to it. Include any events that may have troubled you, even if they didn’t create any serious problems for you at the time or don’t seem related to the current problem. If medical treatments were involved, please note these also.

Please email your responses to me at mm@mmilani.com.


Consultation Fees

The fee for consultations is $125/hour. Consultations for aggression, separation anxiety and other complex problems average 2-2.5 hours. However, in most cases the consultation plus the handouts and 8 weeks of conscientious email follow-up included in the fee usually suffice to get a workable program up and running.

For clinic appointments, please call the Westminster Animal Hospital at 802-722-4196 and they will arrange a time and give you directions to the clinic if needed. To arrange a phone consultation, please let me know when you’re available so we can set up a time.

For phone consultations, please call me at 603-542-7227 at the agreed upon time. Within 24-hours of the consultation, I’ll email you the relevant handouts and an email invoice with a link to PayPal’s secure online payment center. There you may use your MasterCard, Visa, Discover, or American Express credit card. You do not need a PayPal account to use this service. If you do not have Internet access, please let me know and we can make other arrangements.