Pre-Consultation Behavior History Form

Pre-Consultation Behavior History Form
Thank you for scheduling a behavioral consultation with Whisker Wellness Center. This history form gathers information about your cat's behavior, lifestyle, and environment. Please complete this form at least two business days prior to your appointment. This enables our team to review and prepare for your case, allowing for in-depth discussion as we formulate a treatment plan together. Please expect to spend 20 minutes completing this form.
Client Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact E-mail Address*
example@example.com
Cat’s Information
Cat’s Name
Age
Breed
Color
Weight
Gender
Spayed/Neutered? If so, at what age?
Declawed? If so, at what age?
Your Cat’s Background
How old was your cat when it joined your family?
Where did you get your cat?
YesNo
If your cat has had previous owners, how many has your cat had? Why was your cat rehomed?
Your Cat’s Environment
Who is the primary caregiver for your cat?
YesNo
Name

First NameLast Name
Gender
Age
Relationship with your cat?
What do you feed your cat? (Please indicate brand name, whether dry or canned, and amount fed per day. Please also note any treats fed.)
YesNo
Please define
Where does your cat eat?
YesNo
Please define
What type of home do you live in? (house, apartment, etc)
How long have you and your cat lived in this home?
How many square feet of your home can your cat access?
YesNo
Name
Species
Breed
Sex
Age
Age when acquired?
Relationship with the cat
YesNo
Name #2
Species
Breed
Sex
Age
Age when acquired?
Relationship with the cat
YesNo
Name #3
Species
Breed
Sex
Age
Age when acquired?
Relationship with the cat
YesNo
Please indicate the level of supervision your cat has when going outdoors (such as on a harness, in a fenced yard, or allowed to roam freely).
YesNo
What type of posts and where are they located?
Does your cat use the scratching post(s)?
YesNo
What does he/she scratch?
Where does your cat spend most of its time during the day?
Where does your cat sleep at night?
Your Cat’s Social Behavior
Which person(s) is your cat most attached to?
Which person(s) play(s) with your cat? Please note frequency and what/how your cat plays with people.
YesNo
Which kind(s)?
Does your cat come when called? Does your cat hide when called?
How does your cat react when you come home?
Which other pet(s) is your cat most attached to?
Your Cat’s Likes
No reactionAvoidsResistsGrowls/BitesPurrsOther
How does your cat respond to being held?
How does your cat respond to being greeted by you?
How does your cat respond to being petted?
How does your cat respond to being bathed?
How does your cat respond to nail trimming?
How does your cat respond to friends visiting the home?
How does your cat respond to strangers visiting the home?
How does your cat respond to children?
How does your cat respond to his/her veterinarian?
Your Cat’s Elimination Habits
How did you introduce your cat to his/her litter box(es)?
Age when litter trained:
How many litter boxes do you have in the home?
What type of litter box(es) do you have? (covered or uncovered, automatic, etc)
What type(s) of cat litter do you use? Is it scented?
Do you use any litter box liners or additives for the cat litter?
Where is/are the litter box(es) located?
Who cleans the litter box(es)?
If you use clumping litter, how often is/are the litter box(es) scooped?
How often is/are the litter box(es) completely emptied?
How often is/are the litter box(es) washed?
YesNo
If so, please note where your cat has eliminated. Include whether it was urine and/or feces, the room of your home, where in the room your cat has eliminated, and how often this occurs.
Your Cat’s Medical History
Name(s) of previous veterinarian(s)
YesNo
Please describe
YesNo

YesNo
Please define
YesNo
Please define
What is your cat’s main behavioral problem (why are you scheduling this consultation)?
Please describe when the behavior problem first began and how frequent the problem behavior is. Please also note if you have attempted treatment at home or in conjunction with another veterinarian.
Please attach any photos or videos of your cat that may be helpful to demonstrate the problematic behavior here.

Cancelof
Should be Empty:

Rows	Name	Dose	Quantity
Medication #1
Medication #2
Medication #3

Pre-Consultation Behavior History Form

Cat’s Information

Your Cat’s Background

Your Cat’s Environment

Your Cat’s Social Behavior

Your Cat’s Likes

Your Cat’s Elimination Habits

Your Cat’s Medical History