Jones Animal Behavior: Feline History

Jones Animal Behavior

Feline Behavior History Form
Who may I thank for referring you to me?
Owner Information
Legal Owner Full Name*

First NameLast Name
Email*
Phone Number*

Area CodePhone Number
Other owner/caregiver/foster(s)
Other Email
example@example.com
Other Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Zip
House color & parking instructions (for home visits)
Primary Pet Information

If you have more than one pet involved, please choose the primary pet here. You will have the opportunity to describe other pets below.
Cat's Name*
Breed or mix (if known)
Current Age*
Sex*

MaleNeutered MaleFemaleSpayed Female
Declawed*

NoFront onlyAll 4 paws
Does your cat have extra toes?

noFront onlyall 4pawsunknown
Where did you get this pet?*
What do you know about this pet's history?*
How long has this pet lived with you?*
Family Make Up

Describes all HUMANS in this cat's life

	name	age	pronouns	relationship (live together, visit frequently, recent left/passed, get along, conflict, etc.)
1
2
3
4

Describes all ANIMALS in this cat's life

	name	age	species (cat, dog, bird, other)	relationship (live together, visit frequently, recent left/passed, get along, conflict etc)
1
2
3
4

Is your cat having issues with another pet in your home?*

Yes, one other petYes, Multiple other petsNo
Describe the other pet involved
Describe another pet involved (if relevant)
Describe another pet involved (if relevant)
The Behaviors
Describe the most concerning behavior you want to address*
Describe the most concerning behavior you want to address*
Describe any other concerning behavior you want to address*
Describe any additional concerning behaviors
Are you prepared for it to take time to resolve, up to several months or more?

YesI can't do thatUncertain/undecidedI cannot wait more than a couple of weeks
Have you considered other options, should this problem not be resolvable to your satisfaction?

Giving up the pet is not an optionI have or may consider rehoming my petI have or may consider taking my pet to a shelterI have or may consider euthanizing my petUncertain/undecided
Training History
How do you typically reward good behavior? (check all that apply)

PettingVerbal praiseTreats/foodToys/playI don't knowOther
How do you typically correct unwanted/bad behavior? (check all that apply)

Physical (Spanking, nose tap, etc)Verbal (Scold, No!, AhhAhh!, Tsst!, etc)Noise (Squirt bottle, penny can, clap hands, etc)I don'tOther
Please list any professionals you have discussed your concerns with. as well as their recommendations
What have you specifically tried to resolve the problems in the past?
How did the pet respond to what you described above?

Got worseGot betterNo changeUncertainOther
Health, Nutrition, Exercise
Name of your vet clinic and the vet you prefer (if any)*
Did you discuss your behavior concerns with your vet? Any recommendations?
Date of most recent exam and notable comments*
List any current, recent, or past injuries or illnesses*
List medications, supplements, etc. including flea, tick, etc. protection*
Please submit proof of rabies vaccination (ensure scan or photo is clear, up to 1024KB)

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Please submit any other relevant records, or provide at time of visit

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Do you have pet insurance?

YesNo
List any food sensitivities or allergies
What brand(s) of food do you feed?
Describe this cat's feeding (Check all that apply)

Dry kibbleCanned foodRaw or homemadeDry available all day/free choiceDry fed by scheduleCanned available all day/free choiceCanned fed by scheduleOther
How does this cat access water? (check all that apply)

BowlFountainFaucetCleaned dailyCleaned weeklyCleaned rarelyOther
Indicate cat's play preferences (check all that apply)

Doesn't really play at allPrefers solo playPrefers play with others (humans, pets, etc)Prefers toysRarely plays with toysPrefers "chasing" (fishing/flirt pole, laser, fetch, etc.) playPrefers "batting" (mouse, ball, etc) playPrefers "wrestle" playPrefers "zoomie" (running, leaping, etc.) playOther
Cat goes outside (check all that apply)

NeverIn catio onlyWhen leashedWhen supervisedAt scheduled timesAt nightDuring dayIn/out wheneverUnsupervisedOther
Litter Box Details
Is your cat urinating or defecating outside of the box*

YesNo

What materials is cat URINATING on? (ex: carpet, tile, laundry, etc.)
WHERE is the urine occurring? (ex: basement, son's bedroom, etc.)
What materials is cat DEFECATING on?
WHERE is the feces occurring?
How would you describe the elimination?

Large urine puddles on flat or horizontal surfaceSmall urine puddles on flat or horizontal surfaceUrine on vertical surfaces, such as wallsUrine is dark in color, smells funny or strong, etc.Feces is soft (does not hold it's shape)Feces is firm, moist (would flatten if stepped on)Feces is hard, dry (would crumble if stepped on)Other

How often do you scoop?

Multiple times per dayOnce dailyA few times a weekWeeklyLess than weeklyOther
How often do you fully empty box and replace litter?

At least weeklyA few times a monthAround once a month or moreOther
Most recent fecal and results
Most recent urinalysis and results
Most recent imaging (xrays, ultrasound, etc.) and results
Destructive Scratching Details
Is your cat scratching your belongings?*

Yes and I want it to stopYes but I don't careNo
Describe your scratching posts

Have noneHave 1Have 2-3Have 4+Sisel ropeCardboardCarpetHangs or stands upright/verticallyLies flat/horizontally on the floorCat uses it regularlyCat uses it sometimesCat rarely or never uses itIs sturdy and doesn't move when cat scratches itWobbles, swings, or otherwise moves during scratchingOther
What kinds of surfaces are being scratched that you don't like?

Couch, chair, human bed, or other furnitureCarpet or throw rugsWoodwork, posts, or railsWalls, wallpaperWindow screensFabricLeatherWoodOther
Describe nail care
What is being scratched that you don't like?
Describe your cat's nail care

Nails are not/rarely trimmednever trimmedGrind nailsTrimmed weeklyTrimmed monthlyI trimVet trimsOther
Aggression Information
Is your cat displaying aggression (hiss, growl, swat, etc.)?*

YesNo
Has this cat ever:*

Bitten accidentally (not playfully)Scratched accidentally (not playfully)Bitten intentionallyScratched or swatted intentionallyGrowled or hissedCaused bruising or skin dents with teethCaused bruising or skin dents with nailsScratched skin or some blood from tooth contactScratched skin or some blood from nail contactShallow tooth puncture(s)Shallow nail puncture(s)Deep tooth puncture(s)Deep nail puncture(s)Multiple bites in one incidentMedical attention required for victimOther
Who has aggression been directed toward?*

An adultA childA catA dog"Family" that lives/lived in home"Friend" of the cat that doesn't live withStrangersOther
Has this cat ever shown aggression when*

Being picked up (ex: for affection, to be moved, etc)Being pushed/nudged (ex: to move over on couch, accidentally during sleep, to get off bed, etc.)Body handling (ex: grooming, cleaning/medicating ears, pulling something out of fur, inspecting feet, trimming nails etc.)Being cornered or caughtWhen stressed, nervous, anxious, afraid, etc.Other
Describe most severe instances:
Provide any additional behaviors and/or information.
Mentee Shadowing

Would you allow a mentee to shadow me in your appointment?
(Note: mentee will not give advice, participate, nor touch your pet unless instructed to do so by me and with your permission).
Yes, I would allow someone to shadowNo, I prefer no one else attend
Agreement, Waiver & Release

Please review the following and check below to accept and proceed.
Should be Empty:

	Location	height of lowest side	length/ width	other details
Box 1
Box 2
Box 3
Box 4

	At least daily	At least weekly	At least monthly	Rarely	Never	Other
Urine
Feces