Feeling Pawsitive Canine Intake Form

Feeling Pawsitive Feline Intake Form
The information you provide below will be used by Dr. Hilliard, Resident in the American College of Veterinary Behaviorists, during your consultation to develop a diagnosis and plan of treatment.

Please fill it out as completely as you can.

Please submit this form at least 4 days prior to your pet's appointment date.
Full Name*

First NameLast Name
Spouse Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
How best do you learn new information?

VerbalVisualBoth

Your Family Veterinarian's Contact Information
Family Veterinarian
Hospital Name
Hospital Email
Veterinarian's Phone Number
Do you authorize us to send a summary of the consultation to your family veterinarian?

YesNoDo you authorize us to send a summary of the consultation to your family veterinarian?

Your Cat's Information
Name
Breed
Cat's Birthday
Current Weight
Sex

MaleFemale
Color
Fur length
Where did you acquire your cat? (ex: shelter, breeder, friend, etc)
Why did you decide to acquire a cat? (Companion / Protection / Playmate for other cat/ Etc)
What made you choose this cat?
How old was your cat when you acquired him/her?
Declawed/ Tendonectomize
If yes, what age
If yes, were any of these medications given at the time of surgery?

Meloxicam/MetacamFentanylpatchAntibioticsOther
Have you previously owned cats?

Behavior History
What is the main behavioral problem or complaint?
How long has this behavior been going on?
How serious would you rank this behavior?

Very seriousSeriousNot seriousOther
How often does this behavior occur?

DailyWeeklyMonthlyOther
Please give a detailed description of the most recent incident. Please include dates of occurrence
How old was your cat when he/she first began showing signs of this behavior?
Please give a detailed description of the very first incident you remember. Please include the date
Have there been changes in frequency or exhibition of the behavior problem?
What steps have been taken to resolve the behavior problem?
What will you do if this behavior cannot be corrected?
Please list any other behavior problems
What is your goal for this consultation? What would you like to see accomplished?

Medical History
Please describe any previous or current medical problems of the cat
Is your cat currently on any medication or special diet?

YesNo
Please list all current medications including heartworm, flea and tick prevention
Please list all vaccines given within the last year (include dates given)

Your Cat's Environment

Please describe all the people living in the household now, starting with yourself
Name, age, sex of each person
On a scale of 1 to 10 describe the relationship each person has with the cat (1 = hate 10 = love)
How many hours is each person away from home per day
What type of home do you live in?

ApartmentDuplexFarmSingle FamilyOther
How many square feet of the house does the cat have access to?
Has the household changed since the cat was acquired?
If you answered "yes" to the last question please describe (such as addition of family member, addition of pet, move, etc.)
How many times have you moved with this cat since acquiring him/her
Were there previous owners of this cat?
If you answered "yes" to the above question -number of previous owners for this cat and reason for surrendering the cat

Other animals

List all animals in the household in the order they were acquired, including pets who have died within the last year
Do you have (or have you had at any point during the last year) any other animals in the home?
If yes, please share the following for each animal: Name, Species, Breed, Age, Sex, Age when obtained
On a scale of 1 to 10 describe the relationship with the cat (1 = hate 10 = love)
Has your cat ever been outside?
Is your cat currently allowed to go outside?

YesNo
If yes, is he/she supervised when outdoors?

YesNo
Is your cat harness or leash trained?
Is there a scratching post available for your cat?
If yes, what type of posts and where are they located?
Does the cat scratch on other objects?
If yes, what else?

Feeling Pawsitive Feline Intake Form