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!
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.
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*
Sex and status*

Male NeuteredMale IntactFemale SpayedFemale Intact
Breed (if known). Type 'DSH' for the typical Domestic Short Hair.Type a question
Declawed?

NoYesIf yes, front only?If yes, all 4?
Where did you get this cat?*

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?*
Have you had a cat before? How long have you had a cat(s)? (check all that apply)

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. *

You are human #1! For each relationship aspect below, check boxes to indicate relationship status of primary cat with each other human listed (SKIP columns 2-5 if you are living alone).

	Adult Human #1	Adult Human #2	Adult Human #3	Child #1	Child #2
Most bonded to
Also bonded to (if more than 1 person)
Who feeds?
Who also feeds? (if more than 1 person)
Who cleans litterboxes?
Who else cleans litterboxes

List names and ages of other pets in the household.*
Does cat go outside*

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
How often does this behavior happen?*

Several times a dayDailySeveral times a weekSeveral times a monthNot sure (I don't always see it)Other
If you see the behavior, can you stop / interrupt it?

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)? *
Are you prepared for this issue to take time to resolve, up to several months or more?*

YesWow, didn't relize it would be that long, but ok!I can't do thatUncertain/undecided at this point
Have you considered other options, should this problem not be resolvable to your satisfaction?

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
Do you typically reward good behavior? If so, how? (check all that apply)*

Never thought about thisVerbal praise / pettingFood or treatsPlay timeOther
Pick the statement that describes most closely your cat's typical exercise on an average week (for indoor only cats)*

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
How do you typically correct unwanted/bad behavior? (check all that apply)*

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?*
How did the cat respond to what you described above?

Got worseGot betterNo changeuncertain
Brief Vet History
If you know, approximate date of most recent vet exam and notable comments

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)*

	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.

Cat Guardian / Owner

Cat's Information

Household information

Behavior History

Environment & Prior Behavior Modification

Brief Vet History