Feline Behavior Request & Questionnaire (Updated Aug 2022)

Your Pet's Information
Has your pet ever visited Mount Laurel Animal Hospital?*

YesNo, they have never been seen at your facility.
Pet’s Name*
Pet's Age (or date of birth, if known)*
Sex & Alteration Status*
Breed*
Coat/fur/hair color*
Ex: brown & white

Primary Vet Information

Pleae have your pet's veterinary records emailed to Appointments@mlahvet.com or fax Attn: Behavioral Medicine to (856) 231-8393.
Primary Veterinary Hospital/Clinic Name: *
Primary Veterinarian's Name:
Primary Veterinarian's Phone
Primary Veterinarian's E-Mail
example@example.com
Primary Veterinarian's Address

Street Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Referral Information
Who referred you to MLAH's Behavioral Service Department?*

Please list all of the people living in your household, including yourself:*

	Name	Age	Gender Identity	Pronouns	Avg. Hours NOT Home Per Day	Quality of Relationship with Cat
Yourself
Person 2 (Notate relationship to yourself)
Person 3 (Notate relationship to yourself)
Person 4 (Notate relationship to yourself)
Person 5 (Notate relationship to yourself)
Person 6 (Notate relationship to yourself)

Please list all of the animals living in your household, in the sequence they were obtained:*

	Name	Species + Breed	Sex	Spayed/Neutered?	Age Obtained	Age Now	Quality of Relationship w Cat
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5
Pet 6

Please fill out the table below in regard to your cat's behavior(s) that you would like to address:*

	Details of behavior - please include dates and details of recent incidents	Age at which behavior began
Behavior 1
Behavior 2
Behavior 3

How have the behaviors progressed over time? For example, "occasionally urinated on the carpet at 2 years of age, but stopped using the box entirely a year later."*
Has the frequency or the intensity of the behavior changed since it first began?*

YesNo
If so, how and when?

BACKGROUND INFORMATION
How long have you had your cat?*
How old was your cat when you first got them?*
If unknown, please make best guess.
Where did you get your cat from?*
What was the reason you acquired your cat?*
Has your cat had other owners?*

YesNo
If yes, do you know why your cat was given up by previous owners?
Did you meet your cat's parents or do you have any information about their littermates?*

YesNo
If yes, please describe:
Did their parents or littermates engage in similar behaviors?

YesNoUnknown
If yes, what behaviors were exhibited and by whom?
How does your cat react to strangers?*
How does your cat behave in veterinary offices and while being examined? *
Have you owned cats before?*

YesNo

DAILY SCHEDULE
Please select the option that best describes your cat's current lifestyle:*

Indoors onlyOutdoors onlyPrimarily indoorsPrimarily outdoors
On average per day, how many hours does your cat spend indoors?
On average per day, how many hours does your cat spend outdoors?
Does your cat have access to go inside/outside through a cat door?

YesNo
When indoors, if your cat restricted to a specific area or room in the house? Please describe.
On average per day, how many times do you play with toys or games with your cat?*
On average, how long does each play session last (in minutes)?*
Where does your cat sleep?*
Is your cat very active at night?*

YesNo
If yes, please describe:

DIET AND FEEDING
Who feeds your cat?*
What do you feed your cat? Please be specific.*
Please include brand name & if you feed them canned vs dry food
How many meals is your cat fed each day or are they fed free choice?*
How much food do you feed your cat per day? *
Where is your cat's food bowl located?*
Does your cat have a good appetite?*

YesNo
If no, please explain:
What is your cat's favorite treat or human food? *
i.e. Pounce treats, tuna, etc.

EXPECTATIONS
What are your expectations for your Behavioral Medicine appointment? *
Is there anything else you would like to add about your pet's behavior? *
If you feel that a map or drawing of your house may be helpful, please upload here. It is helpful to know where the litterboxes, feeding stations, sleeping areas, cat towers, etc. are located.

Cancelof
Should be Empty:

	Hides	Escapes	Urinates	Defecates	Dilates pupils	Hisses	Vocalizes	Puffs Up (Fur/tail)	Other	None of these responses
Cat is home with family member
Visitor enters home
Visitor approaches/interacts with cat
Cat is home with family but separated from family members
Cat is home alone
Another household cat approaches
Household dog approaches
At veterinary office
At groomer's
New object in home
Unfamiliar animal approaches
Loud noises
Owner is cleaning/renovating

	No aggression	Growls, swats, shows other aggressive behavior without biting	Bites (makes contact)	Situation does not apply
Family member stares at cat
Family member reaches over or bends over cat
Family member pets cat
Family member hugs/kisses cat
Family member lifts cat
Family member approaches cat while resting
Family member pushes/pulls cat (ie. off furniture)
Family member enters or leaves room cat is in
Family member approaches/disturbs cat while eating
Cat's ears or eyes are cleaned or treated
Cat's nails are trimmed
Cat is brushed/combed
Dog approaches cat while eating
Another cat approaches cat while eating
Cat encounters other cat near the litter box
Another cat approaches/disturbs cat while resting
Dog approaches/disturbs cat while resting
Cat approaches another household cat while resting
Cat approaches another household cat who is eating
Cat is in the veterinary waiting room
Veterinary staff member handles/examines cat
Cat is removed from or put back in carrier
Cat is verbally scolded or yelled at
Cat is physically punished (hit)
Unfamiliar person (adult) approaches cat
Unfamiliar person (adult) speaks to/pets cat
Unfamiliar child approaches or interacts with cat
Response to infants or toddlers
Unfamiliar person approaches/passes window while cat is indoors
Unfamiliar cat approaches/passes window while cat is indoors
Unfamiliar cat approaches/interacts with cat outside
Unfamiliar dog approaches/passes window while cat is indoors

	Write the litterbox # next to the type of litter used	Location of box in house
Plain clay
Clumping/scoopable
Playground sand
Sawdust/woodchips
Newspaper - pelleted
Shredded paper
Paper towels
Potting soil
Pine shaving
Wheat
Deodorized
Disposable cardboard tray
None (empty box)
Anything you can get with a coupon
Other:

	Name of Medication	Strength of medication	How many pills are given per dose?	How often do they receive this medication?
Medication #1
Medication #2
Medication #3
Medication #4

Feline Behavior Consult Request & Questionnaire

	Date	Diagnosis	Treatment (including medications and dosage)	Outcome
Diagnosis #1
Diagnosis #2
Diagnosis #3
Diagnosis #4
Diagnosis #5