Behavior Questionnaire for Cats
PATIENT INFO
Pet's Name
*
Owner's First Name
*
Owner's Last Name
*
Breed
*
Age
*
Sex
*
Please Select
Female
Male
Color
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Neutered/Spayed?
Yes
No
HOME ENVIRONMENT
Please list the people, including yourself, living in your household
*
Rows
Name
Age
Pronouns
Relationship (i.e. self, spouse)
Occupation (Optional but sometimes helpful)
Average # of hours away from home per day
Quality of relationship with patient
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Home Environment, cont.
Please list all the animals in the household in the sequence they were obtained
*
Rows
Name
Species
Breed
Sex (M/F)
Neutered?
Age obtained
Age now
Quality of relationship with patient we are seeing
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5
Pet 6
BEHAVIOR HISTORY
Please fill out the information below in regard to your cat's primary behavior problems and other problems you would like addressed
Problem #1
*
Please include dates and details of recent incidents
0/150
Age at which problem #1 began
*
Problem #2
Please include dates and details of recent incidents
0/150
Age at which problem #2 began
Problem #3
Please include dates and details of recent incidents
0/150
At which age did problem #3 began
How have the problems progressed over time? For example, "the cat occasionally urinated on carpet 2 years of age, but stopped using the box entirely a year later."
*
Has the frequency or the intensity of the occurrence of the behavior changed since the problem started?
*
Yes
No
If so, how and when?
BACKGROUND INFORMATION
3. Where did you get your cat?
*
4. Has this cat had other owners?
*
Yes
No
If yes, how many?
5. Why was the cat given up by the previous owners?
9. Do you know if the parents or the littermates engages in similar behaviors?
*
Yes they did/do
No they don't/haven't
Don't know
FEARS AND ANXIETIES
Please complete the table below. Please check all that apply.
Rows
Hide
Escape
Urinate
Defecate
Dilates pupils
Hisses
Vocalize
Puffs up (fur/tail)
Other
Cat is home with family
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
AGGRESSION SCREEN FOR CATS
General Interactions: The following chart provides information about aggression, its intensity, and in what situation it is elicited. For each situation listed, check your cat's worst reaction in the past. These questions refer to situations in the past. Please do not do these things to determine your cat's reaction. If he or she has never been in a particular situation, please check "situation does not apply."
*
Rows
No aggression
Growls, swats, shows other aggressive behavior without biting
Bites (makes contact)
Situation does not apply
Family member pets cat
Family member hugs/kissed cat
Family member lifts cat
Family member approaches cat while resting
Family member pushes/pulls cat (e.g., off furniture)
Family member enters or leaves room cat is in
Family member approaches/disturbs cat while eating
Grooming: The following chart provides information about aggression, its intensity, and in what situation it is elicited. For each situation listed, check your cat's worst reaction in the past. These questions refer to situations in the past. Please do not do these things to determine your cat's reaction. If he or she has never been in a particular situation, please check "situation does not apply."
*
Rows
No aggression
Growls, swats, shows other aggressive behavior without biting
Bites (makes contact)
Situation does not apply
Cat's ears or are cleaned or treated
Cat's nails are trimmed
Cat is brushed/combed
Interactions with other household pets: The following chart provides information about aggression, its intensity, and in what situation it is elicited. For each situation listed, check your cat's worst reaction in the past. These questions refer to situations in the past. Please do not do these things to determine your cat's reaction. If he or she has never been in a particular situation, please check "situation does not apply."
*
Rows
No aggression
Growls, swats, shows other aggressive behavior without biting
Bites (makes contact)
Situation does not apply
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 who is resting
Cat approaches another household cat who is eating
Veterinary visits: The following chart provides information about aggression, its intensity, and in what situation it is elicited. For each situation listed, check your cat's worst reaction in the past. These questions refer to situations in the past. Please do not do these things to determine your cat's reaction. If he or she has never been in a particular situation, please check "situation does not apply."
*
Rows
No aggression
Growls, swats, shows other aggressive behavior without biting
Bites (makes contact)
Situation does not apply
Cat is in waiting room
Veterinarian/staff member handles/examines cat
Cat is removed from or put back in carrier
Punishment: The following chart provides information about aggression, its intensity, and in what situation it is elicited. For each situation listed, check your cat's worst reaction in the past. These questions refer to situations in the past. Please do not do these things to determine your cat's reaction. If he or she has never been in a particular situation, please check "situation does not apply."
*
Rows
No aggression
Growls, swats, shows other aggressive behavior without biting
Bites (makes contact)
Situation does not apply
Cat is verbally scolded or yelled at
Cat is physically punished (hit)
Response to strangers: The following chart provides information about aggression, its intensity, and in what situation it is elicited. For each situation listed, check your cat's worst reaction in the past. These questions refer to situations in the past. Please do not do these things to determine your cat's reaction. If he or she has never been in a particular situation, please check "situation does not apply."
*
Rows
No aggression
Growls, swats, shows other aggressive behavior without biting
Bites (makes contact)
Situation does not apply
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
Response to unfamiliar animals: The following chart provides information about aggression, its intensity, and in what situation it is elicited. For each situation listed, check your cat's worst reaction in the past. These questions refer to situations in the past. Please do not do these things to determine your cat's reaction. If he or she has never been in a particular situation, please check "situation does not apply."
*
Rows
No aggression
Growls, swats, shows other aggressive behavior without biting
Bites (makes contact)
Situation does not apply
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
ENVIRONMENT
1. What type of area do you live in (Urban, suburban, etc.)?
*
2. What type of home do you live in (studio, apartment, house)?
*
3. Has your household changed since acquiring your cat?
*
Yes
No
If so, how?
DAILY SCHEDULE
1. Is your cat:
*
Indoors only
Outdoors only
Primarily indoors
Primarily outdoors
Other
If your cat is primarily indoors: on average, per day, spends how many hours outside?
If your cat is primarily outdoors: on average, per day, spends how many hours outside?
2. Does your cat have access to the outside through a cat door?
*
Yes
No
3. If kept indoors, is your cat restricted to a specific area or room in the house?
Yes
No
Please describe
4. How many times do you play with toys or play games with the cat, daily (on average)?
*
5. How long does each play session last, on average (in minutes)?
*
6. Where does your pet sleep?
*
8. Is your cat very active at night?
*
Yes
No
Please describe
DIET AND FEEDING
2. What do you feed your cat? (Please be specific, i.e. brand name, canned vs. dry)
*
3. How many meals is your cat fed each day or is he/she fed free choice?
*
5. Where is your cat's food bowl?
*
Does your cat have a good appetite?
*
Yes
No
Please explain
7. What is your cat's favorite treat or human food (i.e. Pounce treats, tuna)?
*
ELIMINATION BEHAVIOR
How many litter boxes do you have?
*
0
1
2
3
4
5
Other
2. Please describe the litter boxes by checking all that apply per box
Rows
Litter Box 1
Litter Box 2
Litter Box 3
Litter Box 4
Litter Box 5
Open
Covered
Large
Small
Deep
Shallow
Liner (unscented)
Liner (scented)
No liner
Litter (see questions below)
3. What kind of litter material is used in the box(es)?
*
4. How frequently is the urine or feces scooped?
*
5. How frequently is the litter entirely changed?
*
6. How frequently is the litter box washed and the contents replaced?
*
7. Are deodorants such as bleach or Lysol used in the cleaning process?
*
Yes
No
Will the cat immediately used a freshly cleaned litter box?
*
Yes
No
Unsure
9. Will the cat eliminate in the presence of other animals or people?
*
Yes
No
Unsure
10. Does the cat ever vocalize while it eliminates?
*
Yes
No
Unsure
11. Does the cat ever run out of the box after eliminating?
*
Yes
No
Unsure
12. Does your cat ever eliminate outside the box, in the house?
*
Yes
No
If so, does he or she
Urinate
Defecate
Both
How do you clean up afterwards? (include product(s) used)
13. Describe, in detail, how your cat uses the litter box. For example, does he or she scratch in the litter before eliminating? Cover up feces? Scratch outside the box?
*
MEDICAL HISTORY
1. At what age was your cat neutered/spayed (if applicable)?
Reason
2. If your cat is not neutered has he/she ever been bred?
Yes
No
Unsure
3. Are you planning to breed your cat?
*
Yes
No
Unsure
Is your cat declawed?
*
Yes
No
If so, which feet?
Front
Back
All Four
Age when declawed
5. Is your pet currently receiving flea prevention?
*
Yes
No
If so, please list the type
Has your pet been on any behavioral medications in the past?
*
Yes
No
Please list any behavioral medications/supplements you have administered to your pet
Rows
Date
Treatment
Outcome
Medication/Supplement 1
Medication/Supplement 2
Medication/Supplement 3
7. Is your pet currently on any medications?
*
Yes
No
Please list any medications/supplements you administer to your pet
MEDICAL PROBLEMS: Please list any previously diagnosed medical problems and how they were treated (including heart murmurs, kidney disease, constipation, etc.)
Rows
Date
Diagnosis
Treatment (including medications and dosage)
Outcome
Medical Problem 1
Medical Problem 2
Medical Problem 3
Medical Problem 4
Medical Problem 5
8. Why have you kept the cat despite its behavioral problem?
*
BITE HISTORY
1. If your cat has ever bitten anyone, please list the total number of bites and describe each incident
2. Please list the number of bites that broke skin
3. Please list the number of bites reported to public health authorities, and to whom: (i.e. local authorities, hospital, humane society, etc:
4. Was there legal action taken against you as a result of the bite(s)?
Yes
No
5. Have you ever considered finding another home for this cat?
*
Yes
No
7. Have you considered euthanasia (putting your cat to sleep)?
*
Yes
No
GOALS
What are your goals for your behavior appointment?
*
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