Your name
Cat's Name
Date of Birth
MM
DD
YYYY
Sex
-
Female Spayed
Male Neutered
Female
Male
If this cat is neutered/spayed, at what age?
Color(s)
Weight
*
Date of Last Rabies Vaccine
MM
DD
YYYY
Rabies Vaccine valid for
-
1 year
3 years
What is the main behavior problem you wish to address at this appointment?
Describe when the problem first began
Describe the most recent incident of this problem
Describe any other significant incidents
Describe changes in your cat's body language or facial expressions before, during, or after the incidents
How frequently does this problem occur?
-
>10 times/day
1-10 times/day
1-6 times/week
<1 time/week
<1 time/month
Is the frequency...?
-
Increasing
Decreasing
Unchanged
What percent of time that your cat is in a potentially problematic situation does the problem behavior occur?
-
<25%
25-50%
51-75%
76-100%
Describe what you've tried to correct the problem and what your cat's response has been
How serious do you find this problem?
-
Mild
Moderate
Severe
Intolerable
Have you considered...
-
Dedicated to keeping this cat
Rehoming this cat
Euthanizing this cat
List other problem behaviors in order of importance to you
What would you like to see as an outcome for your upcoming appointment?
How old was this cat when acquired?
Where did you obtain this cat?
-
Shelter - primary (open admission, "pound")
Shelter - secondary (rescue organization)
Foster home
Previous owner
Hobby breeder
Performance breeder (show)
Pet Store
Other
Behavior of cat's parents/littermates (if known)
Describe previous home(s) (if known)
Why did you choose this cat?
Have you had other cats before?
-
Grew up with
As an adult
Both grew up with and as an adult
No
List any major household changes since acquiring this cat
e.g. moves, illness/death of pets/people, added new people/pets to the household, etc.
List any major illnesses/surgeries (include dates)
List ALL medications/treatments your cat is currently receiving
Include heart worm, flea prevention, dietary supplements, herbal/homeopathic treatments. Provide NAME OF MEDICATION, DOSAGE/FREQUENCY, DATE STARTED, ANY SIDE EFFECTS
Previous BEHAVIOR-MODIFYING MEDICATIONS?
Please list all medications previously used for behavior problems.
Provide NAME OF MEDICATION, DOSAGE/FREQUENCY, DATE STARTED, ANY SIDE EFFECTS, OVERALL EFFECTS
When and where is your cat fed?
Who feeds your cat?
What do you feed your cat?
What are your cat's eating habits?
-
Eats right away
Picky eater
Anxious eater
Guards food from people
Guards food from cats
Other
Does your cat go outside?
-
No
Yes, only supervised in enclosed yard
Yes, only supervised on harness
Yes, only during the day
Yes, only at night
Yes, both day and night
If YES, how much time does s/he spend outside daily?
Where does s/he go?
Describe a typical 24 hour day in your cat's life
Start with when and where your cat wakes up in the morning, include feeding, and play times. If behavior problems occur at particular times of the day include that information.
Total number of litter boxes in the house
Number of covered boxes
Number of uncovered boxes
Number of automatic boxes
Locations of boxes
Type of litter used
-
Clay
Clumping/scoopable
Crystals
Pellets (pine, wheat, etc)
Other
How often is the box scooped out?
How often is the box emptied out and cleaned?
What do you use to clean the box?
House soiling (urine)
-
No
When owner present
When owner gone
Don't know
House soiling (feces)
-
No
When owner present
When owner gone
Don't know
Excessive meowing
-
No
When owner present
When owner gone
Don't know
Destructive chewing
-
No
When owner present
When owner gone
Don't know
Self licking/chewing
-
No
When owner present
When owner gone
Don't know
Pacing/repetitive behavior
-
No
When owner present
When owner gone
Don't know
Consuming non-food objects
-
No
When owner present
When owner gone
Don't know
Cirling/chasing tail/freezing
-
No
When owner present
When owner gone
Don't know
Reaction to houseguests
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Reaction to children/babies
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Reaction to dogs
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Carrier
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Car rides
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Veterinary visits
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Loud noises
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Petting cat
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Picking up cat
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Verbal reprimand
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Physical reprimand
-
Happy
Neutral
Fear/anxiety/hides
Hiss/growl
Bite/scratch
Don't know/don't do
Has your cat ever bitten a person?
-
Yes
No
If YES, describe the circumstances and the victim's age, gender
Please include any additional information you'd like me to know
