Questionnaire Behavioural Medicine

Questionnaire Behavioural Medicine - Cat

Please complete the following questionnaire as best you can. There are many questions, please do not feel you have to answer them in detail, we will have time for this during the consultation. The main aim is for me to have some information in advance, so I can prepare myself for you and your cat/s and also so that we can focus on the important points and not spend time collecting background information. Thank you in advance for your time!
Your email address*
example@example.com
Date of the initial consultation*

TagMonatJahr
Datum
Your contact details
name*

first namelast name
Address*

street / house number

zip codeLand

citycountry
Phone number*
Where did you hear about us?

vet practicevet hospitalfriendsmediainternetother
Your cat's vet practcie (name, city, email, phone number)

Consent for the exchange of information with your veterinary practice

	ja	nein
May we contact your veterinary practice to obtain medical information about your pet?
May we pass on information about your pet to your veterinary practice?

Your cat
your cat's name*
breed*
sex*

female intactfemale neuteredmale intactmale neuteredmale chemically neutered
Did you observe any change in behaviour after castration? If yes, please describe
date of birth*
current weight (in kg)*
age at adoption*
How would you describe your cat's personality?
What does your cat love most?*
What are your cat's strengths? What do you love most about your cat?*

The current problem
Behaviour: Please describe the current behavioural problem:*
Beginning: How old was your cat when s/he started showing the behaviour? Please describe the first incident you remember:
Development: How has the behaviour developped over time? Has it improved, stayed the same or gotten worse?
Frequency: How often does the behaviour occur (e.g. per day or per week or per year)?
Recovery: how long does it take your cat to recover from a stressful situation?

Intensity / suffering: On a scale of 1-10, how bad is the current situation for you (= the humans) and for your cat? 1 = absolutely no problem, 10 = worst imaginable situation*

	degree of suffering
for you
for your cat

Reasons: Do you have an idea / a gut feeling as to why your cat is behaving like this?
Treatment attempts: What have you already tried to tackle the problem? How successful were the attempts? What worked, what didn't?
Worries: What is the biggest problem/worry for you?*
Wishes: What do you hope to gain from the behavioural consultation?*
Further information: Would you like to provide us with further information that is important to you regarding the problem?

	your cat's behaviours in these situations
alone
with other cats within the same household
with you
with familiar people
with unfamiliar people
with other animals
other

	name, age and relationship to cat
adults
children
other cats
other animals

	locations
horizontal surfaces
vertical surfaces

	information regarding your cat's sleep behaviour
where does your cat sleep at night?
where does your cat sleep/rest during the day?
About how many hours per 24/ does your cat sleep?
Does your cat dream?
Does your cat sleep calmly during the night?

Communication and social behaviour

Communication: how do you tell your cat when s/he has done someting...

	How do you react when your cat has done something...
...good
...bad

Learning: how fast does your cat learn?

fastmediumslowit dependsother
Concentration: How would you rate your cat's ability to concentrate?

How does your cat behave during the following encounters?

	your cat's behaviour when meeting..
cats in the same household
unfamiliar cats
family members
familiar people at home
familiar people outside
unfamiliar people at home
unfamiliar people outside
children
other animals

How does your cat behave in the following situations?

	Your cat's behaviour
New places (e.g. moving house, holidays, ...)
Change in routines (e.g. left alone during holidays, visitors for longer periods of time, new family member, ...)
New objects, things that were not there before (e.g. rubbish bags, new furniture, ...)
Many stimuli (e.g. party, many guests, ...)
visual stimuli (e.g. other cats outside, birds, ...)
Sounds (e.g. thunderstorms, fireworks, wind, rain, metallic noises, ...)
Smells (e.g. perfume, smells from outside, food, ...)
Touch (e.g. stroking, manual therapy, clinical examination, ...)
Emotional stimuli (e.g. tense mood, arguments, happiness, ...)

Further information: Is there any further information you would like to give us?

	never	sometimes	often	previously, but not anymore	I don't know
flight
freeze
seeking proximity
trembling
excessive meowing/screaming
hissing
scratching
biting without injuries
biting with injuries
raising hackles
overgrooming him-/herself
scratching him-/herself excessively
chasing his/her tail, turning in circles
chasing shadows or lights
physical restlessness / nervousness
high arousability
panting
hypervigilance
destruction
following you around everywhere
other

	never	sometimes	often	excessively	I don't know
fear
panic
anxiety
anger
irritation
frustration
sadness
depression
jealousy
happiness
positive anticipation
contentment
affection / love
empathy
gratitude
pride
curiosity
patience
other

	situation(s)	behaviours / signs
stressed
fearful/anxious
aggressive
happy

	current	previously
Medication
Supplements
Manual therapy (e.g. osteopathy, chiropractice, acupuncture, etc.)
Other

	brand / composition	time of day
dry food
wet food
home cooked
raw
other

Questionnaire Behavioural Medicine - Cat

Your contact details

Your cat

The current problem

Your cat's general behaviour

Physical Health

Current Living Environment

Origin and Development

Everyday Life

Communication and social behaviour

Report and Further Services

	yes	after a while	no	it depends	not applicable	I don't know
at home alone
at home with you
at home with the whole family
at home with familiar guests
at home with unfamiliar guests
other

	yes	no
May we take video recordings and photos of your cat(s) during the consultation?
May we use these recordings for teaching purposes (students / lectures)?
May we use photographs of your cat(s) (without people) for publication purposes, e.g. handouts, articles or books?