Request A Progress Evaluation

Progress Evaluation or Re-evaluation with Dr Shana

Requesting an appointment is easy! Simply fill out the form below and you will be contacted. Please note completing this form does not confirm your appointment.
Please complete one form for each cat
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Pet's Name*
What type of progress evaluation are you looking to schedule*

Routine Progress EvaluationMy pet is having problems
What are your goals for this appointment? Please be specific.*

BEHAVIORAL CONCERNS: Please list your pet’s current issues and indicate whether they are pre-existing or new since your last visit. For pre-existing issues, please note what changes there have been. For new issues, please note when the behavior started and the severity of the problem.*

	Pre-Existing Problem	Worse	% of Improvement in Intensity (ex <25%, 25%-50%, %0%-75%, >75%	% of Improvement in Frequency (ex <25%, 25%-50%, %0%-75%, >75%
Problem 1
Problem 2
Problem 3
Problem 4
Problem 5

New Problems

	List Problem	Date Began	Not Serious	Fairly Serious	Very Serious
Problem 1
Problem 2
Problem 3
Problem 4
Problem 5

Please give us detailed description(s) of recent representative events of each current problem. Include the location, cat’s body postures, any people present, any triggers, your reaction, and the final outcome.
Date and Incident #1
Date and Incident #2
Date and Incident #3
Date and Incident #4

CHANGES TO HOUSEHOLD*

	Y/N	Details
Arrival of new household member (please list name)
Is anyone in the household pregnant or adopting a child?
Departure or death of a household member (please list name)
Moved to new home
Schedule change (gained/lost job, school, etc.)
Pet added (list name and information)
Death or relinquishment of other pet (list name and information)

Have there been any other changes in your household besides what was listed above?*

YesNo
If yes, please explain

BEHAVIOR MEDICATIONS: Please complete the table below in regard to your pet’s current medications, dosages, and apparent effectiveness.*

	MED NAME	DOSE (the mg strength)	FREQUENCY (how often you give it)	REPONSE	SIDE EFFECTS (if any)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Non-Behavior Medications: Please complete the table below in regard to your pet’s current medications, dosages, and apparent effectiveness.*

	MED NAME	DOSE (the mg strength)	FREQUENCY (how often you give it)	REPONSE	SIDE EFFECTS (if any)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5

Elimination Behavior
How many litter boxes do you have and where are the located?*

Type Of Litter Box

	Litter Box 1	Litter Box 2	Litter Box 3	Litter Box 4	Litter Box 5	Litter Box 6
Open
Covered
Large
Small
Deep
Shallow
Liner (unscented)
Liner (scented)
No liner

Type of Litter*

	Litter Box 1	Litter Box 2	Litter Box 3	Litter Box 4	Litter Box 5	Litter Box 6
Plain Clay
Clumping/Scoopable
Playground Sand
Sawdust/Woodchips
Newpaper- pelleted
Shredded Paper
Paper Towels
Potting Soil
Pine Shavings
Wheat
Deodorized
Disposable Cardboard Tray
None (Empty Box)
What you can get with a coupon
Other

How frequently is the urine or feces scooped?*
How frequently is the litter entirely changed?*
How frequently is the litter box washed?*
Are deodorants such as bleach or Lysol used in the cleaning process*
Will the cat immediately use a freshly cleaned litter box*
Will the cat eliminate in the presence of other animals or people*
Does the cat ever vocalize while it eliminates?*
Does the cat ever run out of the box after eliminating?*
Does your cat ever eliminate outside of the box, in the house?*

YesNo
If so, they

UrinateDefecateBoth
How do you clean up afterwards? (include products used)
Describe, in detail, how your cat uses the litter box. For example, does he or she scratchin the litter before eliminating? Cover up feces? Scratch outside the box?*
Medical History

Please list any newly diagnosed medical problems and how they were treated.

	Date	Diagnosis	Treatment (including medications and dosage)	Outcome
Medical Problem 1
Medical Problem 2
Medical Problem 3
Medical Problem 4
Medical Problem 5

BITE HISTORY
Has your pet bitten since your last visit? *
Please list the number of bites that broke skin:
Please list the number of bites reported to public health authorities, and to whom: (i.e. local authorities, hospital, humane society, etc.):
CURRENT STATUS
Have you recently considered finding another home for this pet?*

YesNo
Have you recently considered euthanasia (putting your pet to sleep)?*

YesNo
Has someone recently recommended you euthanize your pet?*

YesNo
Has the behavioral medicine clinic helped you with your pet?*
What else would you like us to know about your pet and his/her current situation?
Day of the Week*

Thursday (open availability)Thursday but I have time limitationsThursday does not work for me
What are your time limitations. We will try to accommodate to your schedule; however, please know that we may not be able to as she has a set schedule.
Preferred Time Frame (pick at least 2)*

Sunday (any time)3-5pm5-7pmNone of these work for me
Let us know what your availability is. Please know that we will try to accommodate to your schedule pending Dr. Gilbert-Gregory's availability we may not be able as she has specific days reserved for mobile appointments.
Please list specific dates that will NOT work for you over the next 2 months. *
Please know that we will try to accommodate to your schedule pending Dr. Gilbert-Gregory's availability; however, we may not be able.*

I understand
Should be Empty:

Progress Evaluation or Re-evaluation with Dr Shana

Please complete one form for each cat

Elimination Behavior

Medical History

BITE HISTORY

CURRENT STATUS