Feline Pet Behavior Form

Preferred Method of Contact*

Phone

Either

Patient Information

Pet Name

Breed

Age

Sex/Status (neutered, spayed, intact)

How long have you had your cat?

Where did you get your cat from?

Has your cat had other owners? If so, how many?

Please briefly describe their other living situations or owners:

If applicable, please explain why your cat was previously relinquished:

Please list any previously diagnosed medical conditions:

Please list any medications your pet is currently taking:

Please list any medication reactions your pet has had before:

Have you considered euthanasia or rehoming your pet prior to your visit to us?

Environmental

How many people live in the home?

How often do you have visitors?

Are there any individuals with medical conditions or concerns that we should know about?

If you feel that there is a specific relationship with your cat that is important, please describe it:

Has there been any significant changes in your household’s routine in the past 6 months? If yes, please describe:

Tell us about your pet’s environment/access to outdoors:

Indoor only

Outdoor only

Indoor/outdoor with free access

Indoor, outside under supervision

Indoor, walked on a leash outside

Indoor, confined outdoor access

Other

Other animals that live in the house:

Where does your cat sleep at night?

Health, Wellness, Welfare

What is your cat’s general activity level?

Low

Average

High

Excessive

Does your pet take naps during the day when you’re gone?

Does your pet sleep through the night?

Have you noticed any change in your pet’s sleeping patterns in the past 3 months?

Does your cat have any issues with vomiting, diarrhea, constipation, or decreased appetite? If yes, please describe:

How many play sessions does your cat get per day?

Does your cat have allergies or food sensitivities?

What do you feed your cat, and how?

Behavior Problem Information

What are your goals for this appointment?

List the major concern for which you are seeking help:

What age did the problem start?

How often is the problem happening?

>1x/week

1x/day

3-6x/week

1-3x/week

<1x/week

Please give a complete description of the concern or event that occurs for which you are seeking help:

Are there additional concerns that you wish to address at this visit?

Aggressive Behaviors

If your cat displays aggressive behaviors, please fill out this section. If not, go on to the next section.

Number of bites:

Number of severe scratches:

Number of bites that broke the skin:

Number of bites that were reported to public health authorities:

Who is your cat aggressive towards?

When is your cat aggressive?

Fears/Anxieties

If your cat is fearful or displays anxiety, please fill out this section. If not, go onto the next section.

When your cat is separated, from the following (check all that apply):

Cries, meows, howls

Urinates outside the box

Hides

Puffs up

Defecates outside the box

Destroys

Other

When visitors enter the home (check all that apply):

Cries, meows, howls

Urinates outside the box

Hides

Puffs up

Defecates outside the box

Destroys

Escapes/avoids

Stalks

Attacks

Hisses

Other

A new object in the home (check all that apply):

Cries, meows, howls

Urinates outside the box

Hides

Puffs up

Defecates outside the box

Destroys

Escapes/avoids

Stalks

Attacks

Hisses

Other

Unfamiliar animal approaches (check all that apply):

Cries, meows, howls

Urinates outside the box

Hides

Puffs up

Defecates outside the box

Destroys

Escapes/avoids

Stalks

Attacks

Hisses

Other

Loud noises (check all that apply):

Cries, meows, howls

Urinates outside the box

Hides

Puffs up

Defecates outside the box

Destroys

Escapes/avoids

Stalks

Attacks

Hisses

Please check all the previous treatments tried:

Fluoxetine (Prozac)

Amitriptyline

Paroxetine

Alprazolam

Clomipramine

Gabapentin

Increased exercise

Separation of cats

Increase play/enrichment

Please check all the previous supplements tried:

Zylkene

Feliway

Rescue remedy

Solliquin

Feliway multi-cat

Acupuncture

L-theanine

Calming collar

Thundershirt

Feline Pet Behavior Form

Preferred Method of Contact*

Patient Information

Pet Name

Breed

Age

Sex/Status (neutered, spayed, intact)

How long have you had your cat?

Where did you get your cat from?

Has your cat had other owners? If so, how many?

Please briefly describe their other living situations or owners:

If applicable, please explain why your cat was previously relinquished:

Please list any previously diagnosed medical conditions:

Please list any medications your pet is currently taking:

Please list any medication reactions your pet has had before:

Have you considered euthanasia or rehoming your pet prior to your visit to us?

Environmental

How many people live in the home?

How often do you have visitors?

Are there any individuals with medical conditions or concerns that we should know about?

If you feel that there is a specific relationship with your cat that is important, please describe it:

Has there been any significant changes in your household’s routine in the past 6 months? If yes, please describe:

Tell us about your pet’s environment/access to outdoors:

Other animals that live in the house:

Where does your cat sleep at night?

Health, Wellness, Welfare

What is your cat’s general activity level?

Does your pet take naps during the day when you’re gone?

Does your pet sleep through the night?

Have you noticed any change in your pet’s sleeping patterns in the past 3 months?

Does your cat have any issues with vomiting, diarrhea, constipation, or decreased appetite? If yes, please describe:

How many play sessions does your cat get per day?

Does your cat have allergies or food sensitivities?

What do you feed your cat, and how?

Behavior Problem Information

What are your goals for this appointment?

List the major concern for which you are seeking help:

What age did the problem start?

How often is the problem happening?

Please give a complete description of the concern or event that occurs for which you are seeking help:

Are there additional concerns that you wish to address at this visit?

Aggressive BehaviorsIf your cat displays aggressive behaviors, please fill out this section. If not, go on to the next section.

Number of bites:

Number of severe scratches:

Number of bites that broke the skin:

Number of bites that were reported to public health authorities:

Who is your cat aggressive towards?

When is your cat aggressive?

Fears/AnxietiesIf your cat is fearful or displays anxiety, please fill out this section. If not, go onto the next section.

When your cat is separated, from the following (check all that apply):

When visitors enter the home (check all that apply):

A new object in the home (check all that apply):

Unfamiliar animal approaches (check all that apply):

Loud noises (check all that apply):

Please check all the previous treatments tried:

Please check all the previous supplements tried:

Is there anything else you would like to share with us about your pet?

Aggressive Behaviors

If your cat displays aggressive behaviors, please fill out this section. If not, go on to the next section.

Fears/Anxieties

If your cat is fearful or displays anxiety, please fill out this section. If not, go onto the next section.