Feline Behavior History Form The Purrfect Cat

Please fill this out as best you can to help me prepare for our consult.

Thanks and looking forward to talking with you!
Disclaimer

By submitting this questionnaire, I understand that the behavioral recommendations given by Chris Aytug are in no way a substitute for veterinary care. I understand that the success of a behavior modification plan depends upon my compliance with the instructions and that not all behavior problems can be solved. In some cases, only an improvement in the behavior may be the best outcome. I release Chris Aytug from any and all liability regarding the health and behavior of my pets, the safety of all people in the household who interact with the cat(s), damage or loss to my property, and in regard to any aspect of the advice given.
Who may I thank for referring you to me or how did you find my information?*
Cat Guardian / Owner
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name of any other owner/caregiver/foster(s)
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
House color & parking instructions (for home visits)
Cat's Information
Cat's name - the one you have concerns about*
Age when you got cat & current age*
Male NeuteredMale IntactFemale SpayedFemale Intact
Breed (if known). Type 'DSH' for the typical Domestic Short Hair.Type a question
NoYesIf yes, front only?If yes, all 4?
Rescue/shelterBreederFound outside somewhereFriends/familyOther
What do you know about his/her history (trauma, illnesses, previous owner etc)?*
How long have they lived with you?*
This is my first cat (or cats if more than 1)I've had cats for 1-5 yearsI've had cats for 6-10 yearsI've had cats for 11+ years
Household information
Please list the names and ages of other humans in the house.*
Describe your dwelling and how many floors are there? Include a basement that the cats would go into as a story: For example, 2 story house, 2 story house + basement, studio apartment, 2 story townhouse, etc. *
List names and ages of other pets in the household.*
Describe your cat’s relationship with these other pets, if any:
In a few words, describe your cat's personality
How does your cat respond when visitors come over?
No, inside onlyInside with a lanai or "catio" access at willScheduled time outside (on a leash, with supervision)Comes in at night (usually)Goes in and out when everOnly when I go outside, no leashOther
Behavior History
Describe the behavior(s) you would like to address in the primary cat*
How disruptive is this behavior to your household or personal/relationship peace?

1

2

3

4

5

1 is No Disruption, 5 is Very disruptive
Several times a dayDailySeveral times a weekSeveral times a monthNot sure (I don't always see it)Other
I don't usually see itYes, I can usually stop itI can stop it sometimesI usually can't stop itI can never stop itOther
Describe any other concerning behaviors (with any pets)
Can you remember when the behavior started? Any change in the cat's routine or household around the time it started that might have upset the cat? (new pet, loud noises, another pet passing or being ill, owner being ill, moving furniture, house renovation, leaving the cats for vacation, new roommate/partner/spouse, visitors, neighbor issues, etc)? *
YesWow, didn't relize it would be that long, but ok!I can't do thatUncertain/undecided at this point
Giving up the pet is not an optionI have considered options other than giving up petUncertain / undecidedOther
What is your goal / are your goals for this pet and any work you do with a behavior consultant?
Environment & Prior Behavior Modification
Never thought about thisVerbal praise / pettingFood or treatsPlay timeOther
I play with kitty every dayI play with kitty when I have some time, 1-2x/weekKitty has other pets to entertain/exercise withI have tried, but my kitty doesn't want to play
Physical (spank, nose tap, push off table etc)Verbal (No! AhhAhh!, Tsst etc.)Noise (squirt, air blast, penny can, clap hands etc))I don't (they do pretty much what they want)Other
Did you discuss your concerns with your vet? Any recommendations?
Have you discussed these concerns with anyone else? If so, who?
What, if anything, have you specifically tried to resolve the problem(s) in the past?*
Got worseGot betterNo changeuncertain
Brief Vet History
If you know, approximate date of most recent vet exam

MonthDayYear
Date
List any current, recent, or past injuries or illnesses*
List medications, supplements, etc. including flea, tick, etc. protection*
List any food sensitivities or allergies
What brand(s) of food do you feed?

Describe this cat's feeding (Check all that apply)*

Rows	Available all day (free feed)	Once / day	Twice/day	3x/day
Dry kibble
Wet Food
Raw / homemade
Other

How many litter boxes do you have?*
How often are the litter box(es) scooped?*
Is your cat(s) urinating or defecating outside of the box**
If you desire an in-home visit, please be prepared to submit proof of rabies vaccination (ensure scan or photo is clear, up to 1024KB). Please submit any other relevant records, or provide at time of visit

Please fill this out as best you can to help me prepare for our consult.

Disclaimer

Cat Guardian / Owner

Cat's Information

Household information

Behavior History

Environment & Prior Behavior Modification

Brief Vet History