• Canine History Form & Consultation Booking

    Please allow 30-60 minutes to complete this form. A copy of your responses will be emailed to you once submitted.

  • Thank you for taking the time to fill out this history form - it provides vital information Dr. Squair needs to assess and plan treatment for your pet ahead of your appointment. 

    Because this is a longer form, we highly recommend saving your progress as you go so nothing is lost if you need to step away. Saving requires a free Jotform account, but no subscription is needed.

    Once submitted, you will move on to a deposit to confirm your booking, followed by scheduling your appointment time online. We recommend all primary caregivers attend, so it may help to check everyone’s availability ahead of time. After that, we will email you short consent and practice policy forms to review and sign.

    If you run into any issues or have questions along the way, email us at hello@prairiecrocusbehaviour.com - we're happy to help.

     

  • Page 2 of 14

  • Pet Parent Information

  • Today's Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Please share how your learned about us*
  • Where are you located, and what type of appointment are you wanting to schedule?*

  • **NOTE: Telemedicine appointments are for Manitoba clients who find it difficult to travel to Winnipeg, or who have other circumstances that prevent an in-person visit. If you’re not sure which appointment type fits, please email us at hello@prairiecrocusbehaviour.com.

  • Format: (000) 000-0000.
  • Owner's Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Please share your preferred pronoun(s)
  • Does your pet have more than one owner?*
  • Format: (000) 000-0000.
  • Please share your preferred pronoun(s)

  • Page 3 of 14

  • Pet Information

  • Pet's Date of Birth *
     - -
    2 digit day, 2 digit month, 4 digit year
  • Pet's Sex*
  • Where did you obtain your dog?*
  • Date your dog joined your household*
     - -
    2 digit day, 2 digit month, 4 digit year
  • How many previous owners has your dog had (not including breeder, but including fosters)?*
  • Format: (000) 000-0000.

  • Page 4 of 14

  • Household Information

  • Please list the people (including yourself) currently living within the household *
    Rows
  • Please list all pets in the household (including the patient) in the order they were obtained. Please enter N/A if not applicable*
    Rows
  • Household changes that have occurred since acquiring your pet - Please select all that apply*
  • Living Environment - Please select all that apply*
  • If in a multiple story building - how do you enter/exit the building?
  • Yard Environment - Please select all that apply*
  • Outdoor Access - Please select all that apply*

  • Page 5 of 14

  • Behaviour Concerns

    Some portions of this section may not apply to your pet, but the information you provide helps us build a more complete picture for your assessment. We appreciate any details you're able to share.
  • The main behavioural concerns for my pet include (please select all that apply):*

  • Describe a recent, specific example. Please try to include:

    • Approximate date
    • What happened
    • Where it occurred and who (people/animals) was present or nearby
    • Your pet's body language before/during/after (if observed)
    • Anything happening around your pet at the time.

    Multiple examples can be provided if available

  • Describe a recent, specific example. Please try to include:

    • Approximate date
    • What happened
    • Where it occurred and who (people/animals) was present or nearby
    • Your pet's body language before/during/after (if observed)
    • Anything happening around your pet at the time.

    Multiple examples can be provided if available

  • Describe a recent, specific example. Please try to include:

    • Approximate date
    • What happened
    • Where it occurred and who (people/animals) was present or nearby
    • Your pet's body language before/during/after (if observed)
    • Anything happening around your pet at the time.

    Multiple examples can be provided if available

  • Page 6 of 14

  • Videos of Behaviour Concerns

  • If you have any videos and/or photos of the concerning behaviour, please upload them here.

    If you don't currently have any, but can safely capture some before the appointment, please bring them to share with Dr. Squair or email them to hello@prairiecrocusbehaviour.com prior to the appointment.

    Please do NOT attempt to capture footage in any situation where a person or animal could be harmed. Do not provoke aggression or reactivity just to get it on video. Dr. Squair doesn't need to witness these behaviours firsthand to evaluate your pet - discussing behaviour patterns and history, along with assessing body language in clinic, gives her a clear clinical picture.

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  • Page 7 of 14

  • Aggression Screening

  • Has your dog ever bitten or attempted to bite a person?*
  • People your dog has shown aggression toward? Select all that apply*
  • Bite pattern observed toward PEOPLE? Select all that apply*
  • If your dog has bitten a person(s), what injuries were sustained? Mark all that apply.*
  • Total number of bites to PEOPLE - TOUCHED skin*
  • Total number of bites to PEOPLE - BROKE skin*
  • Has your dog ever bitten or attempted to bite a pet (another dog or other animal)?*
  • Pets your dog has shown aggression toward? Select all that apply*
  • If your dog has shown aggression toward another pet in the home, what are the triggers? Select all that apply*
  • Bite pattern observed toward PETS? Select all that apply*
  • If your dog has bitten a pet(s), what injuries were sustained? Select all that apply*
  • Total number of bites to PETS - TOUCHED skin*
  • Total number of bites to PETS - BROKE skin*
  • Has your dog been declared "At Risk" or "Dangerous" by any Municipality?*
  • Has there ever been any legal action taken as a result of any bites?*

  • Page 8 of 14

  • General Behaviour Screening

  • Behaviour Patterns within the Home

  • What best describes your dog's sleeping patterns?*
  • What behaviours do you observe when you have GUEST(S) at your home? Please indicate all that apply*
    Rows
  • If you or another family member approach your dog when they have the listed item/space, which behaviours do you observe? Please indicate all that apply*
    Rows
  • If you or another family member handle your dog, which behaviours do you observe? Please indicate all that apply*
    Rows

  • Behaviour Patterns when out of the Home/on Walks

  • How does your dog handle travelling in the car? Please check all that apply*
  • How does your dog respond on walks or other times when they see an unfamiliar PERSON? Please indicate all that apply*
    Rows
  • How does your dog respond on walks or other times when they see an unfamiliar DOG? Please indicate all that apply*
    Rows

  • Environment and Behaviours when Separated

  • Does your dog have a kennel/crate or other place of confinement (e.g. laundry room, room with a gate etc.)?*
  • If your dog does have a kennel/crate, please specify what material it is:
  • How does your dog react to their crate/kennel/place of confinement? Check all that apply
  • Where is your dog when you are gone from home?*
  • What does your dog do when you prepare to leave? Check all that apply*
  • Does your dog do any of the following when you are away? Check all that apply*
  • Do you have a camera in the home to observe your pet when you are away?*
  • When your dog has been left home alone, do you typically come home to find that your dog was sleeping?*
  • Does your dog seem frantic to greet you when you return home?*
  • In general, does your dog follow you (or another family member) from room to room?*

  • Response to Noises

  • How does your dog respond to the following noises? Please indicate all that apply*
    Rows
  • What is the longest period of time it has ever taken your dog to recover after a noise event?*

  • Behaviour during Veterinary Appointments

  • How does your dog typically behave during veterinary appointments? Select all that apply*

  • Compulsive Behaviours

  • Does your dog exhibit any of the following to the point of interfering with normal function?*

  • Page 9 of 14

  • Equipment and Training History

  • What type of equipment have you used PREVIOUSLY with your dog?*
  • What type of equipment do you use CURRENTLY with your dog?*
  • Based on your pet's response, do you feel that the tools/methods that you currently use are effective?*
  • What is the training history of your dog?*
  • What types of training methods do you use? Select all that apply.*

  • Page 10 of 14

  • Diet and Feeding

  • Does your dog have any diet restrictions?*
  • How often do you offer food?*
  • Does your dog finish all of their food?*

  • Medical History

    Previous and current medications, major medical history
  • Is your dog currently on any medications or supplements?*
  • Please list current medications and supplements your dog receives, OTHER THAN FOR BEHAVIOUR - if not applicable, enter N/A in box 1*
    Rows

  • E.g. Apoquel, 16 mg, tablet, 1/2 tablet (8 mg), once daily, 8 am, Dec 2025

  • Please list current medications your dog receives as prescribed specifically for BEHAVIOUR - if not applicable, enter N/A in box 1*
    Rows

  • E.g. Gabapentin, 100 mg, capsule, 1 capsule (100 mg), twice daily, 8 am and 8 pm, April 2025

  • Has your dog ever been prescribed behaviour medication(s) in the past?*

  • Page 11 of 14

  • Your Goals and Sentiments

  • Do you feel that your goals or expectations for your pet are attainable?*
  • What are your feeling on the potential use of medications IF recommended as part of your pet's treatment plan?*
  • We understand that living with a pet who is experiencing behavioural challenges can be difficult, and it can affect many parts of your daily life together. To help us better understand your relationship with your pet, please select all of the following that apply to how you currently feel:*
  • Are you concerned that you may have caused the problem?*
  • Do you feel guilty about the problem*
  • Are you considering finding another home for your dog due to behaviour concerns?*
  • If yes or maybe, is this something you would like to discuss during your appointment?*
  • Are you considering euthanasia due to behaviour concerns?*
  • If yes or maybe, is this something you would like to discuss during your appointment?*
  • Has anyone said that you should euthanize your dog?*

  • Please continue to the next page to pay your appointment deposit and book your appointment. Your history form, payment, and appointment booking will all be completed when you press Submit at the very end of the form.

    Need to finish later? Press "Save and Finish Later" and follow Jotform’s instructions to return to your form where you left off.

  • Page 12 of 14

  • Consultation Deposit

  • This deposit secures your place to book a consultation and goes toward the total cost of the appointment. The remainder of the appointment cost ($395 CAD + GST) will be due at the end of your consultation appointment. Following the deposit, you will then gain access to the Prairie Crocus Veterinary Behavioural Medicine calendar on the next page and can schedule yourself in an appointment slot that works best with your schedule.

    If there are any problems, issues, or questions that arise, please reach out by email to hello@prairiecrocusbehaviour.com. Thank you!

  • This deposit secures your place to book a consultation and goes toward the total cost of the appointment. The remainder of the appointment cost ($250 CAD + GST) will be invoiced following your consultation appointment. Following the deposit, you will then gain access to the Prairie Crocus Veterinary Behavioural Medicine calendar on the next page and can schedule yourself in an appointment slot that works best with your schedule.

    If there are any problems, issues, or questions that arise, please reach out by email to hello@prairiecrocusbehaviour.com. Thank you!

  • Prairie Crocus Veterinary Behavioural Medicine Canine Appt Deposit*

    prevnext( X )
      Canine Behaviour Diagnostic Consultation Deposit


      $200.00 CAD$200.00CAD
        
      Total
      $0.00 CAD$0.00CAD

      Credit Card

    • Page 13 of 14

    • Schedule Your Consultation

    • Thank you for completing your history form and confirming your deposit.

      Please schedule your appointment time using the button below, selecting the slot that works best for your schedule (and anyone else who may attend).

      We encourage all primary caregivers, including partners and involved teenagers, to attend so everyone is on the same page with the plan. If someone is unable to attend in person, we are happy to provide a Zoom link so that they can join remotely. 

      Once you have selected an appointment slot, press Submit at the bottom of the next page to send your information to Dr. Squair for review ahead of your appointment.

      If there are any problems, issues, or questions that arise, please reach out by email to hello@prairiecrocusbehaviour.com. Thank you!

    • Canine Behaviour Diagnostic Consultation*

    • Thank you for completing your history form and confirming your deposit.

      Please schedule your appointment time using the button below, selecting the slot that works best for your schedule (and anyone else who may attend).

      We encourage all primary caregivers, including partners and family members, to attend so everyone is on the same page with the plan.

      Once you have selected an appointment slot, press Submit at the bottom of the next page to send your information to Dr. Squair for review ahead of your appointment.

      If there are any problems, issues, or questions that arise, please reach out by email to hello@prairiecrocusbehaviour.com. Thank you!

    • Canine Behaviour Diagnostic Consultation - Telemedicine Appointment*
    • Canine Out-of-Province Collaborative Consultation*

    • Page 14 of 14

    • Information for In-Clinic Visits

    • We encourage all primary caregivers in the household, including spouses, partners, and any family members closely involved in your pet’s care, to attend the initial appointment. Having everyone present means the whole household starts with the same understanding of the diagnosis, recommendations, and behaviour modification plan.

      Children 13 and older who help care for your pet are welcome to attend. We ask that younger children stay home so your pet can settle and everyone can focus on the discussion.

      If you have any questions prior to the appointment, please do not hesitate to reach out via email to hello@prairiecrocusbehaviour.com

       

    • Information for the Zoom Meeting

    • We encourage all primary caregivers in the household, including spouses, partners, and any family members closely involved in your pet’s care, to attend the initial appointment. Having everyone present means the whole household starts with the same understanding of the diagnosis, recommendations, and behaviour modification plan.

      The Zoom link will for the meeting will be sent to you in your calendar invitation and included in your appointment reminder messages.

      If you have any questions prior to the appointment, please do not hesitate to reach out via email to hello@prairiecrocusbehaviour.com

       

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