Separation Anxiety Questionnaire
General Info
Pet Parent's First Name
*
Pet Parent's Last Name
*
Phone
*
Email
*
Dog's Name
*
Dog's Breed
*
Dog's Gender
*
Male
Female
Dog's Weight
*
If you adopted, which rescue did you use?
*
How long have you had this dog?
*
1. Please select the behaviors you have observed while home in preparation for leaving (dog in different room).
Destructive behavior (not dissecting toys)
Urinating in the home when alone (fully potty trained)
Defecating in the home when alone (fully potty trained)
Vocalization: whining, barking, howling (all excessive)
Drooling (excessive)
Heavy panting
Pacing
Attempting or have successfully broken thru crates, windows, doors, gates
Bodily injury
None of these apply to my dog
2. Upon returning home which behaviors have you observed.
Destructive behavior (not dissecting toys)
Urinating in the home when alone (fully potty trained)
Defecating in the home when alone (fully potty trained)
Vocalization: whining, barking, howling (all excessive)
Drooling (excessive)
Heavy panting
Pacing
Attempting or have successfully broken thru crates, windows, doors, gates
Bodily injury
None of these apply to my dog
3. Have you received any comments or complaints from neighbors or a landlord concerning your dog’s behavior when alone?
Yes
No
If you answered yes to question #3, please list expressed concerns. Otherwise skip this section.
4. Have any of the following events occurred in the last few weeks?
Schedule changes (new job, work from home)
Companion animal has passed
Aging or physical changes
Trauma or noise sensitivity (loud thunderstorms)
Moved to a new home or apartment
None of these events have occurred
5. Can your dog take food or eat when alone?
Yes
Sometimes
Never
6. Are you currently able to crate your dog?
Yes
No
If you are able to crate your dog, for how long?
7. If you cannot crate your dog, where do they stay when you must be gone? Large room with a gate, friends, family, daycare/boarding facility?
8. Do you currently utilize a dog walker or pet sitter when gone?
No
Dog Sitter
Dog Walker
Both, depending on the situation
9. Does your dog participate in daycare?
Yes
No
If you answered yes to question #9, please tell us how often your dog participates in doggy daycare. Otherwise skip this section.
10. Do you currently have a camera set up to keep an eye on your dog?
Yes
No
11. Is your dog currently on any behavioral medications?
Yes
No
If you answered yes to question #11, please list the medications, what they are for and how long your dog has been taking them.
12. Please describe the routine you have with your dog prior to leaving. Do they get a meal, long walk, enrichment..etc?
Submit
