Fill out your Canine Consultation Questionnaire online.

Name: FMA Animal Hospital
Address: 4755 Rainbow Blvd, Westwood, KS, 66205, United States
Telephone: 913-262-1600
Price range: $

Please fill out the form as completely as possible.

Owner Information
Name: *
First
Last
Address:
Address Line 1
Address Line 2
City
State
Zip Code
Home Phone:
Cell Phone:
Employer's Name:
Employer's Address:
Address Line 1
City
State
Zip Code
Work Phone:
Email: *
Name of preferred local pharmacy:
Phone:
Fax:
Basic Canine Information
Canine's name: *
Age:
Breed:
Color:
Gender:
Female
Male
Spayed/Neutered?
Yes
No
Age when performed:
Weight:
Date and age when acquired (if known):
Source:
Breeder
Shelter
Stray
Rescue
Other
If Other, please explain:
Reason for obtaining this dog:
Litter size (if known):
Age when weaned (if known):
Raised indoors or outside (if known):
Indoors
Outside
Describe your dog's personality:
Has your dog been bred?
Yes
No
If so, at what age?
How much interaction did the puppy have with people in the first year of life?
What method of house training was used?
Your reaction to mistakes during house training:
Was there any interaction with other puppies and dogs? If so, provide details:
Did your dog attend puppy parties?
Yes
No
Are you the dog's first owner?
Yes
No
Canine Medical History
Please ensure that we have all your pet's medical records
Primary veterinarian:
Clinic name:
Phone:
Fax:
Date of last veterinary visit:
Please list the most recent set of vaccinations received and the date(s):
Date wormed:
Referred by:
Provide medical history (infection/surgeries) and prescribed treatment:
Current/regular medications (such as allergy, heartworm, herbal, over the counter, pain medication, supplements, topical flea and tick treatment) - please specify medication, dose, route, frequency given.Medication: Dose: Route: Frequency Given:
Route administered (oral, topical, eyes, ears, etc.)
Has there been any change in the following? (Please select all that apply):
Eating
Drinking
Please explain change in eating habits:
Please explain change in drinking habits:
Have you noticed any of the following? (Please select all that apply):
Coughing
Sneezing
Vomiting
Diarrhea
Has your dog ever been treated for its behavior in the past?
Yes
No
If so, describe the treatment and medication (if applicable):
Does your dog have seizures or has it ever had any seizures?
Yes
No
Current Human Household Members
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Other Household Pets
Have you owned dogs previously?
Yes
No
Have you owned this breed of dog previously?
Yes
No
Have you owned other pets previously?
Yes
No
Current pets in the household:
Name, Type and Breed:
Age:
Spayed or neutered?
Yes
No
Relationship with dog (fight, play, avoid)
Name, Type and Breed:
Age:
Spayed or neutered?
Yes
No
Relationship with dog (fight, play, avoid)
Name, Type and Breed:
Age:
Spayed or neutered?
Yes
No
Relationship with dog (fight, play, avoid)
Name, Type and Breed:
Age:
Spayed or neutered?
Yes
No
Relationship with dog (fight, play, avoid)
Training
Has your dog ever attended training classes?
Yes
No
If so, provide details (where, when, age, handler):
What types of training techniques were used?
How well did your dog do in class?

Very well Average Poor

Very wellItem #1 Very well
AverageItem #1 Average
PoorItem #1 Poor

If you were asked to leave, please explain why:
How would you rate your dog's learning ability?

Good Average Poor

GoodItem #1 Good
AverageItem #1 Average
PoorItem #1 Poor

What tasks does your dog perform regularly and reliably on cue (e.g. command)? (Please select all that apply):
Sit
Stay
Down
Fetch
Other
If Other, please elaborate:
Does your dog do tricks?
Shake
Rollover
Does your dog pull when on a lead?
Yes
No
Sometimes
Is your dog more obedient in some places than in others?
Yes
No
If so, provide details:
Is your dog more obedient with some people than with others?
Yes
No
If so, provide details:
How do you correct your dog when he/she misbehaves?
What types of training aids have you used (e.g., pinch collar, prong collar, electric shock)?
Diet and Feeding Habits
Type(s) of food:
Dry
Canned
Both
Brand(s) (e.g., Nutro, Eukanuba, Alpo):
Who is primarily responsible for the feeding?
Quantity of food given:
At what approximate time(s) of day is food given?
Where is the dog fed (physical location)?
Where is the dog fed in relation to other dogs in the household?
Is the dog protective of its food (e.g., does it growl, snap, or bite)?
Yes
No
If so, provide details:
Describe your dog's appetite:

Good Average Poor

GoodItem #1 Good
AverageItem #1 Average
PoorItem #1 Poor

At what speed does it typically eat?

Fast Slow

FastItem #1 Fast
SlowItem #1 Slow

Do you have to be present for your dog to eat?
Yes
No
What are your dog's favorite foods?
How much water does your dog drink in a day?
How many water bowls are provided?
Do you add any supplements to your dog's diet?
Yes
No
If so, provide details:
Daily Activities
Where does your dog sleep?
If it sleeps on your bed, who invites it up?
When does your dog get up in the morning?
Does your dog ever wake you at night?
Yes
No
If yes, how often and have you any idea why?
When does your dog get to go outside and how long does it like to stay out for?
How does your dog ask to go outside?
Does your dog roam free in the yard?
Yes
No
If the yard is fenced, what type of material is used?
Vinyl
Wood
Chain Link
Other
If Other, please describe:
Does your dog run the fence-line barking?
Yes
No
If yes, at whom does it bark?
At other dogs
At people
Both
Does your dog enjoy exploring on its own?
Always
Sometimes
Never
What type of exercise does your dog receive?
Walk
Run
Agility training
Other
If Other, provide details:
Is this done on or off a lead?
On lead
Off lead
Provide details of the frequency of exercise:
Is there any specific time devoted to play or training on a daily basis?
Yes
No
Does your dog play games with you or other family members?
Yes
No
If yes, provide details:
Who initiates play?
Dog
Family members
What types of toys does your dog play with?
Balls
Bones
Ropes
Frisbee
Other
If other, provide details:
Where does your dog stay during the day when no one is home?
Crate
Specified room
Free run (in house)
Free run (in fenced yard)
Doggie daycare/camp
What does your dog do as you prepare to depart?
Does your dog bark or whine when you leave?
Yes
No
Typically, how long is your dog left alone without human company on any given day?
Does your dog ever vocalize, engage in destructive behaviors, urinate, or defecate while you are away from home?
Vocalizing
Destructive behaviors
Urination
Defecation
What does your dog do during family meals?
Have there been any changes in your household routine (e.g., new baby, change in working hours)?
Yes
No
If yes, provide details:
List the five things your dog likes the most (e.g., specific activities, food, toys)
Interaction with Family Members
What type of home do you have?
Apartment
House
Condo
Townhome
Other
If other, provide details:
To which areas of your home does your dog have access?
Does your dog have a reaction to handling in any of the following circumstances? (Please select all that apply and elaborate when prompted):
Handling/grooming
Petting or hugging
Disturbed when resting
Disciplining
Walking on the lead
Taking food away
Taking other objects away
Please describe your dog's reaction, the type of aggression they may exhibit (growling, snarling, lunging, nipping, snapping, showing teeth, biting) and who they reacting to (adult owner, child, other individual):
Please describe your dog's reaction, aggression exhibited, and to whom during handling/grooming:
Please describe your dog's reaction, aggression exhibited, and to whom during petting or hugging:
Please describe your dog's reaction, aggression exhibited, and to whom when disturbed during resting:
Please describe your dog's reaction, aggression exhibited, and to whom during disciplining:
Please describe your dog's reaction, aggression exhibited, and to whom when walking on a lead:
Please describe your dog's reaction, aggression exhibited, and to whom when taking food away:
Please describe your dog's reaction, aggression exhibited, and to whom when taking other objects away:
How does your dog behave when visitors come to the house (e.g., barking, door charging)?
Interaction with Others
Is the behavior different towards familiar and unfamiliar people?
Yes
No
If yes, provide details:
Does your dog display aggression (e.g., growling, snarling, snapping, biting) to visitors inside your home?
Yes
No
If yes, provide details:
Does your dog display aggression (e.g., growling, snarling, snapping, biting) to visitors outside your home?
Yes
No
If yes, provide details:
Has your dog ever bitten or attacked anyone?
Yes
No
If yes, how many times?
Are there any regular visitors to the home?
Yes
No
If yes, please provide the information (Name(s), purpose(s), time and days, dog's reaction(s))
What is your dog's response to frequent visitors?
What is your dog's response to occasional visitors?
What is your dog's response to rare visitors?
Please check any of the following that your dog has a negative reaction to and elaborate when prompted:
Familiar men
Familiar women
Familiar children
Unfamiliar men
Unfamiliar women
Unfamiliar children
Familiar dogs
Unfamiliar dogs
Other animals (e.g., cats, squirrels)
Crowds and busy areas
Other dogs (on lead)
Other dogs (off lead)
Where does your dog have negative reactions to familiar men?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to familiar women?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to familiar children?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to unfamiliar men?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to unfamiliar women?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to unfamiliar children?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to familiar dogs?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to unfamiliar dogs?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to other animals?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to crowds and busy areas?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to other dogs on lead?
Inside the home
Outside the home
Details:
Where does your dog have negative reactions to other dogs off lead?
Inside the home
Outside the home
Details:
Other Behaviors
Does your dog show inappropriate mounting or other sexual behavior?
Yes
No
If yes, please specify whom or what is the target:
Is your dog protective of parts of its body (e.g., ears, mouth, feet)?
Yes
No
If yes, please specify which regions:
Does your dog lick or chew itself more than you would expect?
Yes
No
Does your dog display any reaction to loud noises such as thunderstorms or fireworks?
Yes
No
If yes, give details:
Are there any other behaviors that you find objectionable, feel you should mention, or wish to discuss?
Yes
No
If yes, describe these:
The Current Problem
Describe the problem you are currently experiencing with your dog:
How old was the dog when the problem began?
Is this a chronic (constant) or intermittent problem?
Chronic
Intermittent
Where does the problem commonly occur?
How often does it occur?
If the problem is house soiling, does it occur when you are home and/or away?
Home
Away
Both
If the problem is destructive behavior, does it occur when you are home and/or away?
Home
Away
Both
Additional details about the problem:
Is there any legal action pending because of this dog's behavior?
Yes
No
If yes, please explain in detail:
Aggression Section (if applicable)
Describe the most recent incident and the setting in which is occurred (be precise):
Where was the dog?
Where was everyone else in relation to the dog?
What was everyone doing prior to the incident?
What was the dog's body posture (position of ears, tail, face, hair on back)?
What was your reaction or response?
What was the dog's reaction to your response?
Was any form of punishment used?
Yes
No
If so, give details:
Was there a bite wound?
Puncture
Tear
Describe the previous three incidents prior to the most recent incident:
How frequently does this type of incident occur?
Several times a day
Several times a week
Daily
Weekly
Monthly
Other
If other, please explain:
Does this problem occur when the dog is left alone?
Always
Sometimes
Never
Does this problem occur when the family members are present?
Always
Sometimes
Never
What has been done to correct the problem?
Is the problem getting better or worse?
Better
Worse
No Change
Do you suspect any cause?
Relationship with Canine
How would you describe your own and your family's relationship with this dog? (Adult owners & children)
What are your own and your family's feelings about the dog's present behavior? (Adult owners & children)
What is your expectation for change?
Under what circumstances would you consider rehoming this dog?
Under what circumstances would you consider relinquishing this dog to a shelter or rescue?
Under what circumstances would you consider euthanasia?
Video Recordings
Video recordings of the specific problem are extremely helpful for verifying your descriptions. Never* place any person or animal in danger in order to obtain video information. Feel free to bring the video recordings with you (on your phone, tablet, laptop, etc.) to your consultation. Please do not email videos ahead of time.
Upload Videos:

Click or drag files to this area to upload. You can upload up to 5 files.

Describe the scenarios seen in videos:
Message

We proudly serve the pets Westwood, KS and beyond.

We're a full service, state of the art animal hospital located in Westwood and serving the surrounding Kansas City area.

Directions

4755 Rainbow Blvd
Westwood, KS 66205

Click here for directions.

Call Us

913-262-1600

Hours

Mon – Fri: 7 am – 7 pm
Sat: 8am – 5 pm
Wed: Closed from 12:30-2:00 pm

Have a question? Drop us a line and we'll get right back to you.

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