Feline Behavioral History Form

Feline Behavioral History Form

Richmond Campus
At which location are you requesting an appointment?*

FAIRFAX, VA CampusRICHMOND, VA Campus
Primary Owner Name (person filling out the form)*

First NameLast Name
Primary Owner preferred pronouns*

She/herHe/HimThey/ThemOther
Primary Owner Email*
example@example.com
Primary Owner Phone Number*
Please enter a valid phone number.
Co-Owner Name

First NameLast Name
Co-Owner preferred pronouns

She/herHe/HimThey/ThemOther
Co-Owner Email
example@example.com
Co-Owner Phone Number
Please enter a valid phone number.
Address - mailing*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For ease of recognition, please share a photo of your pet for his/her medical record.
Feline/patient name*
Patient date of birth*
Is date of birth known or estimate?*

KnownEstimate
Breed*
Color*
Sex*
Weight (in pounds/lbs)*
Age when spay/neuter performed*
How did you acquire this cat?*

BreederRescueFound/strayOther
Date of adoption/purchase*

MonthDayYear
Date
Age of cat upon adoption/purchase*
Age
History prior to acquisition/adoption (if known)*
How much interaction did he/she have with people and other animals in the first year of life?*
Describe your cat's personality*
Describe the problem(s) you are currently having with your cat*
When did the problem(s) start*
Date of onset or coincidence with life events
How often do the problem(s) occur?*
Ex- once per month, daily, etc
What has been tried to correct the problem(s)?*
Do you suspect any cause?*
Have there been any changes in the household or routine at the time of onset?*
Describe the three most recent incidences:*
Describe the cat's body postures during these incidences?
What was your reaction to the incidences?*
What was your cat's response to your reaction?*
If aggression, what was the result to the victim(s)?*

PunctureScratchBruiseTearNo injury to the victim(s)Not applicable
How often does this type of incidence occur?*

Multiple times per dayDailySeveral times per weekWeeklyMonthlyInfrequently
What has been done to change or correct this problem in the past (even if it hasnt helped)?*
What has helped the current problem, if anything? *
Is this problem getting:*

BetterWorseNo change
Are there any other details surrounding the problem which you feel are relevant?
Is there any legal action (pending or resolved) regarding these incidences?*

No legal actionYes, legal action is pendingLegal action is resolved at the time of consultationUnknown

Human household occupants:*

	Name	Age	Occupation	Relationship to you	Relationship with Patient
Yourself
Others
Others
Others
Others
Others

Animal household occupants:

	Name	Breed & Species	Gender	Age	Relationship with Patient
Other pet
Other pet
Other pet
Other pet
Other pet
Other pet

Have you previously owned cats?*

YesNoYes, but only as a child (family cat)
Have you previously owned this breed of cat?*

YesNo
Where is the cat fed?*
Physical location
Where is the cat fed in relation to the other pets?
If applicable
How do you feed your cat?*

Out of a bowlOut of feeder or puzzle toysA combination of the aboveOther
Do you need to be present for you cat to eat?*

YesNo
Where does your cat sleep?*
Does your cat wake you up at night?*

YesNo
If so, why?
How many hours do you think your cat sleeps per 24 hour day?*
Does your cat seek out high places to rest?*

YesNo
Where can your cat normally be found during the day?*
Is your cat allowed to go outside?*

YesNo
How long does your cat like to be outside?*
If your cat is allowed outside, how do you control access?*
How far does your cat roam?*

Stays in our yardMaybe over to next door neighborsFurther than we can seeI have no idea how far this cat roams
How often do you see other cats outside?*

NeverRarelyOccasionally (3-4 times per week)Daily
What arrangements are made if you are out of town?*

In-home pet sitter that stays overnightBoardingIn-home pet sitter that comes in several times per dayI leave enough food and water out for the duration of our trip
How long (approximately) is your cat left alone without people each day?*
How many litter boxes do you provide?*
Please mark their location on your house map
Has there been a change in litter boxes as a result of today's concerns?*

YesNo
What type, size, and shape of box(es) do you use?*
What brand of litter do you use?*
Are there odor control granules added?*

YesNo
How often is the box scooped of waste?*
How often is the box completely emptied, washed, and the litter fully replaced?*
What do you use to clean the litter box when it is completely washed?*
Does the cat use the box on a daily basis? (Yes/No) and if so, how often per day for urine and feces?*
Does the cat use the box for:*

UrineFecesBoth urine and fecesNeither
What is the cat leaving outside of the litter box?*

Urine onlyFeces onlyBoth urine and fecesNeither, the cat uses the box all the time
If the cat is urinating or defecating outside of the box, how often per week does this occur?*
For how long has the problem elimination been occurring?*
What time of day do you find elimination outside of the litter box?*
When the problem elimination first began, do you remember any inciting event?*
Have you ever seen the cat eliminate outside of the box?*

YesNo
If urine, where is the urine being left outside of the box?*

On a horizontal surface (floor, bed, counter top, etc)On a vertical surface (walls, etc)Both horizontal and vertical surfaces
If you are not the cat's original owner, did the cat have a similar elimination issue outside of the litter box in their previous home(s)?*

YesNoUnknown
Does your cat defend its territory from other cats?*

Yes, from a housemateYes, from outdoor catsNo
Do you ever see this cat physically blocking a housemate from accessing food, litter boxes, rooms, toys or climbing perches?*

YesNo
Do you ever see a housemate physically blocking this cat from accessing food, litter boxes, rooms, toys or climbing perches?*

YesNo
Have you previously worked with a trainer or behaviorist for this cat's behavioral concerns?*

YesNo
With whom have you worked?*
Name of trainer and company. Name of behaviorist.
Is your cat playful?*

YesNo
Is there any time dedicated to play with this cat?*

YesNo
What type of toys does your cat play with?
Does your cat perform any tricks? If so, which ones.
How does your cat respond to cat nip?*
Is your cat declawed?*

NoYes, front 2 paws onlyYes, all 4 paws
At what age was your cat declawed?*
Does your cat use scratching posts, and which type does it prefer?*
Please indicate their location on the house map
Does your cat scratch things that you would prefer they do not?*

NoYes
What type of home do you live in?*

Apartment/condoTownhomeSingle family homeOther
How would you describe your home?*

QuietLively

Does your cat show aggression in any of the following circumstances? Aggression can include any of the following- swatting, hissing, snarling, lunging, nipping, biting. Check box if aggression is shown in those circumstances with those people.

	Primary Owner	Co-owner	Children in household	Other particular person
Handling/Grooming
Petting/Hugging
Playing
Disciplining
Placing in carrier

How does your cat respond when the doorbell rings?*
Is your cat quick to approach visitors?*

YesNoDepends on the visitor

What is your cat's response to the following situations?*

	Indoors	Outdoors
Frequent visitors
Occasional visitors
Unknown men
Unknown women
Unknown children
Other animals
Crowds/busy areas

Does your cat startle at loud noises that are not thunder, fireworks, or gunshots?(ex. if you drop a book, if you clang a pot or pan)*

YesNo
Describe the reaction.*
Describe the behavior.
When does your cat meow?*
When does your cat hiss?*
When does your cat growl?*
When does your cat purr?*
Is your cat aggressive when it is denied something it wants?*

YesNo
Does your cat show inappropriate mounting or sexual behavior?*

YesNo
How does your cat respond to grooming?*
How does your cat respond to handling?*
How does your cat respond to veterinary handling/intervention? Please check ALL that apply:*

Loves vet visits. No fear, stress, or anxiety of any kind. Happy as a clam.Mildly distressed (panting, whining, etc.), but allows veterinary staff to examine, restrain, and perform treatments with no signs of aggression and will still take treats.Moderately distressed (attempts to hide, vocalizations, trembling, will not accept treats, etc.), but no signs of aggression.Severely distressed (shut down and overwhelmed; may urinate, defecate, or express anal glands; may vomit or get diarrhea after visits), but allows veterinary staff to examine, restrain, and perform treatments with no signs of aggression.Has displayed aggression toward vet staff in the form of staring, meowing, hissing, lunging, growling, or swatting.Has displayed aggression toward vet staff in the form of nipping or biting.Must wear a muzzle at the veterinary clinic.According to vet staff, aggression subsides when I am NOT present (ex. patient has been taken into a treatment area in the back).Has been administered or prescribed medication to alleviate fear, anxiety, and stress during veterinary procedures.Has been fully sedated by vet staff in order to safely complete a blood draw, vaccination, nail trim, or other routine procedures such as examination.Veterinary handling/intervention is one of my primary reasons for seeking treatment.
Does your cat lick or groom themselves more than you would expect?*

YesNo
How do you correct your cat when they misbehave? (Ex- squirt bottle, spanking, etc)*
Are there any other behaviors you find objectionable?
What are the primary owner's thoughts about the current problem?*
What are the co-owner's thoughts about the current problem?
What are other family members thoughts about the current problem?
What are the expectations for change?*
What are your goals for treatment?*
Under what circumstances would you rehome this cat?*
Under what circumstances would you place this cat up for adoption or relinquish to a rescue?*
Under what circumstances would you consider euthanasia for this cat?*
What is one thing you LOVE about your cat?*
Territory is everything in a cat's world. Understanding the structure of your cat's territory and the placement of resources within it, will provide valuable insight into your cat's world and the assessment of your cat's behavior.

Please draw a quick map or layout of your home. Indicate the location(s) of the following resources: Food, Water, Litter Boxes, Resting Areas, Climbing Towers, Scratching Posts, Windows, Doors etc. Please also indicate areas of inappropriate elimination, conflict or other undesirable behaviors, if applicable. You may also opt to record a video of these spaces in your home and submit here, or via email at richmond@abwellnesscenter.com.
You may upload the map/video here, email it to us, or bring it with you to your initial consultation appointment. TIP : take a picture of your hand-drawn map for easy upload!

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