Feline Initial Behavior Appointment

Feline Initial Behavior Appointment
Patient's Information
Welcome to our Feline Initial Behavior Appointment Form. We look forward to working with you and your cat!

Important:

It is important to know that this form will require a lot of information and often can take between 15-20 minutes to complete. The information you provide is incredibly important to our team and we appreciate all efforts to fill this form out to the best of your ability.

After you fill this form out in its entirety, be sure to click Submit at the end of the form. You will then be directed to a confirmation page and a copy of your responses will be sent to the email you provide.

If you have submitted your form and have not heard back from our team within 72 hours OR you did not receive an email confirmation of your form submission, check your spam folder then please reach out to us directly at behavior@hickoryvet.com.
Name *
Breed*
Age*
Gender*
Coat Color *
Date of Birth*
(mm/dd/yyyy)
Owner Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Emergency Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Co-Owner Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary Veterinarian *
Primary Veterinarian Phone*
Primary Veterinarian Email *
How did you hear about us?*
Household Information

Please list everyone in your household.
Do you have more people that live in your household?*

YesNo
If yes, then please list the names, ages and relationships (i.e. spouse, children) of everyone living in the household:
Other Pets in Household
Do you have more pets in the household?*

YesNo
If yes, then please list (in order they came into the household) the names, ages, species, sex (ie. Anna, 11yo, dog, spayed female) of the additional pets living in the household:
Type of House
Type of House*

Single Family DetachedApartmentAttached (Rowhouse, Townhouse, Etc.)Other
How long have you lived in this house?*
Since adoption, how many houses have you and your cat lived in?*
Neighborhood Style*

UrbanSuburbanRural
List any major household changes since acquiring this cat (ie moves, illness/death of pets/people, added new people/pets to household etc.)
Acquisition Information
How long have you owned this cat?*
How old was the cat when acquired?*
Where did you obtain this cat?*

Performance Breeder (show)Hobby BreederPrivate Home / Previous OwnerShelter Rescue OrganizationPet StoreOther
Behaviors of cat's parents / litter mates (if known)*
Describe previous homes (if known)*
If obtained from a shelter/rescue, describe the information you were given about cats behavior/ experiences before adoption:*
Why did you choose this breed of cat? *
Why did you choose this individual cat?*
Why did you acquire this cat (check all that apply)*

Adult's petFamily petChildren's petCompanion to other petShowBreedingOther
Spay & Neutering Information
Is this cat neutered / spayed?*

YesNo
If yes, at what age?
Reason for spay/neuter?

Prevent behavior problemHealth/vet recommendedPopulation control/don't want to breedAdoption agreementCorrect behavior problemOther
If you spayed or neutered due to an existing behavior problem, list problems your cat had before neuter/spay that you hoped to correct with surgery:
Did you notice any changes after neutering/spaying?

YesNo
If yes, please describe:
Medical History
List of major illnesses, surgeries and any chronic illness (please be sure to include dates):*
Please list all medications/ treatments your cat is CURRENTLY receiving, including heartworm, flea/ tick preventative/ collars, dietary supplements, herbal/homeopathic treatments:
How many medications is your cat currently receiving?*
If your cat is receiving medication(s), please list below including medication name, dose, frequency given and date medication was started:
Daily Activities/ Routine
When and where is your cat fed?*
Do you use a slow feeder or food dispensing device?*

YesNo
If yes, please describe the feeder/device:
Does your cat have food available all day?*

YesNo
Dry (Brand)*
% of Diet*
Canned (Brand)*
% of Diet*
Raw*
% of Diet*
Other*
% of Diet*
If you feed a special diet (hypoallergenic, grain free etc.) why?
Eating Habits (check all that apply)*

Eats right awayPicky eaterAnxious EaterOther
List types of treats: *
How often does your cat get treats?*
When does your cat get treats? *
Where does your cat sleep at night?*
Where does your cat sleep during the day?*
Does your cat go outside?*

YesNo
If yes, does your cat have

Free access to outside (ie. via pet door)Controlled access
Please describe (ie. only allowed out during day, outside in fenced yard, out on leash, etc.):
Does your cat play with toys?*

YesNo
If yes, what are your cat's favorite toys?
How often does your cat play with toys?

Several times per dayDailySeveral times per weekWeeklyRarelyNever
How often does your cat play with people?*

Several times per dayDailySeveral times per weekWeeklyRarelyNever
How often does your cat play with other animals?*

Several times per dayDailySeveral times per weekWeeklyRarelyNever
How many litter box(es) do you have?
Describe your cat's litter box(es), including location, type of box, size, type of litter and any additives or cleaning products used: *
How frequently are litter boxes scooped?*
How frequently are litter boxes cleaned?*
What cleaning products do you use?*
If there will be or have been any major changes to the daily routine (ie. vacations, owner travels for business, etc.) please describe: *
Does your cat engage in housesoiling at least once weekly?*

NoWhen owner is presentWhen owner is goneDon't know
Does your cat engage in excessive vocalizations at least once weekly?*

NoWhen owner is presentWhen owner is goneDon't know
Does your cat engage in destructive scratching at least once weekly?*

NoWhen owner is presentWhen owner is goneDon't know
Does your cat engage in self licking/chewing at least once weekly?*

NoWhen owner is presentWhen owner is goneDon't know
Does your cat engage in pacing/repetitive behavior at least once weekly?*

NoWhen owner is presentWhen owner is goneDon't know
Does your cat engage in consuming non-food objects at least once weekly?*

NoWhen owner is presentWhen owner is goneDon't know
Does your cat engage in circles/chasing their tail/freezing at least once weekly?*

NoWhen owner is presentWhen owner is goneDon't know
How does your cat react to unfamiliar people at the door?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to unfamiliar people in the home?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to babies?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to children?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to other cats that live in the household?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to other cats (does not live with)?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to dogs in the household?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to other dogs (does not live with)?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to squirrels/birds/etc.?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to carriers?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to car rides?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to the veterinarian's office?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to being left alone?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to thunder?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to loud noises?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
How does your cat react to petting by familiar people?*

HappyNeutralFearfulAnxiousRuns/hidesHiss/growlScratchBiteDon't know/don't do
Primary Behavior Problem
Please fill out this section IN DETAIL. The more thorough you are with this form, the more time it will allow during the appointment to discuss treatments instead of going over your cat's history.
What is the one main behavior problem you wish to address? *
Describe the very first incident of this problem. Try to remember the earliest occurrence of the problem, even if it wasn't as serious as it is now. If you noticed any changes in your cat's body language or facial expression before, during or after the incidents please describe. For example, if your cat is aggressive to people, describe the first time she hissed or growled at someone, not the first bite. Or if your cat has been house soiling, describe the first "accident" you found. If you noticed any changes in your cat's body language or facial expression before, during or after the incidents please describe. *
Date of the first incident and cat's age at the time (approx. date and age is okay): *
Describe, per instructions, the above *most recent* incident*
What is the approx date of the most recent incident?*
Describe, per instructions above, at least one other incident you feel illustrates the problem behavior (if you would like to describe other incidents, that's great!): *
Date of additional incidents: *
How frequently does this behavior occur?*

>10x per day1-10x per day1-6x per week<1x per week<1x per month
Is the frequency...*

IncreasingDecreasingUnchanged
What percent of the time that your cat is in a potentially problematic situation does the problem behavior occur?*

<25%25-50%51-75%76-100%
What have you tried to do to correct this behavior problem and how did your cat respond? *
How serious do you and other members of the household find this problem? *
Has anyone suggested that you euthanize or rehome this cat because of this problem (this is not a recommendation; we just want to know what has been suggested)?*

EuthanizeRehomeNeither
Have you ever considered euthanasia or rehoming your cat because of this problem?*

EuthanizeRehomeNeither
List other problem behaviors in order of importance to you: *
Do we have permission to post pictures on our social media?*

YesNo
Please upload your favorite picture of your pet!

Cancelof
As the representing owner, agent or handler dealing with the individuals who will be working with the pet(s) indicated above, I understand that behavior therapies recommended by Dr. Laurie Bergman may involve some level of risk to the pet(s) and or the handlers, or other people or property in spite of our best efforts to minimize them. I will use my own judgement and common sense when following any recommendations so as not to place people, pets and property at undue risk.

Furthermore, I realize that the clinicians, Hickory Veterinary Hospital and its agents/ employees cannot guarantee that a pet will not be aggressive or cause injury to people or property in the future and I acknowledge that the pet's owner(s) and handler(s) continue to be solely responsible and assume all liability for any future aggression or misbehavior.

By typing my name below, I am freely assuming these risks and shall not hold Hickory Veterinary Hospital or its clinicians, agents, employees or facility owners liable for any loss or injury which may occur to handlers, pet, or other people, other animals or property while using their training and medication treatment recommendations, and I hereby waive any claim for damages arising out of such matters and agree to hold Hickory Veterinary Hospital and its clinicians/ agents/ employees harmless from any such claims.

*** Behavior initial consults are $500 and a 50% deposit is required to schedule.
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Feline Initial Behavior Appointment

Patient's Information

Owner Information

Co-Owner Information

Household Information

Other Pets in Household

Type of House

Acquisition Information

Spay & Neutering Information

Medical History

Please list all medications/ treatments your cat is CURRENTLY receiving, including heartworm, flea/ tick preventative/ collars, dietary supplements, herbal/homeopathic treatments:

Daily Activities/ Routine

Primary Behavior Problem