Behavior History Form

Behavior History Form
Client Information
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Alternative Number
Please enter a valid phone number.
Preferred Pronouns
Patient Information
Pet's Name*
Species*
Breed*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Weight
Color
Primary Veterinary Hospital*
Primary Veterinarian*
Veterinarian Phone Number*
Please enter a valid phone number.
Veterinarian Email
example@example.com
Medical History - Feline
Is your cat spayed or neutered*

YesNo
If yes, what age was the surgery performed
Reason for surgery*

RoutineAttempt to motify behavior
Were there any behavioral changes after the surgery?

YesNo
Is your cat declawed?*

YesNo
Were there any complications?
Do you recall the type of litter used after the procedure?
Provide dates for most recent vaccinations:
Rabies*

MonthDayYear
Date
Feline Distemper*

MonthDayYear
Date
Feline Leukemia*

MonthDayYear
Date
Other

MonthDayYear
Date
List current medical conditions, medications and dosages*
List prior medical conditions, medications and dosages:*
Background Information - cat
Date you adopted your cat*

MonthDayYear
Date
Age at time of adoption*
Days, weeks, months, years*

daysweeksmonthsyears
Where did you get your cat?*

ShelterRescue groupPet shopProfessional breederOther
Is this your cat's first home?*

YesNo
If no, how many previous owners.
Do you know why he/she was given up?
Which traits describe your pet as a kitten?*

FriendlyOutgoingShyFearfulAgressivePlayful
Please indicate the reason you decided to adopt this cat:*

CompanionshipShowOther
Is this your first cat?*

YesNo
How did you select this particular cat over the others?*
Do you know the status of your cat's littermates?
Home Environment- Cat
Describe your home*

Single family homeApartmentTownhomeTrailerOther
Have you relocated since owning this cat?*

YesNo
If yes, please list the approximate date of move
Please list all members of your household: (NAME, AGE (Children), HOURS AWAY FROM HOME)*
Example: Jane, 12 years old. Tom 20 years old, 1 hour away.
Please list all household pets in order adopted:*
Example: Fluffy 1/1/2010, Puff 2/2/2012...
Describe your cat’s relationship to the other household pets:*
Management
Please describe a typical 24-hour day in the life of your cat:*
Example: Metronidazole 50mg tablet given twice a day. Type "none" if your pet is not on any medications or supplements.
Does your cat run unsupervised outdoors?*

YesNo
Do you have an outdoor containment system (“cat fence”)?*

YesNo
Who wakes up first*

YouYour cat
Where does your cat like to sleep when you are sleeping?*
Where is your cat’s favorite resting spot when you are home?*
Describe your cat’s favorite toys:*
Describe any interactive games that you play with your cat and note frequency:*
Does your cat perform any special tricks?*
Does your cat usually follow you from room to room?*

YesNo
Does your cat have free access to the house when you leave?*

YesNo
How does your cat behave when you prepare to leave home?*

No reactionLooks sadAggressive behaviorhides
How does your cat behave when you return home?*

No reactiongreetsBrief excitementhides
Does your cat use a scratching post?*

YesNo
If yes, type of post and location
List any items that your cat chews or scratches, if applicable:
What specific brand and type of food do you feed your cat?*
How long have you been feeding this diet?*
Number of meals:*
Which family members are responsible for feeding?*
Location of food bowl(s):*

KitchenLaundryBasementOther
What are your cat’s favorite treats?
Describe your cat’s reaction to thunderstorms:*

no reactionhidefollow person
Please describe your cat’s overall activity level:*

ExcessiveHighModerateLowVery Low
Behavioral Details - cat
Briefly describe the PRIMARY behavioral concern. Focus on the single most significant issue—additional concerns can be noted later in the form.*
Describe a typical episode:*
The behavior occurs: ___times per day / week / month*
PLEASE ANSWER THE FOLLOWING QUESTIONS FOR THE MAIN PROBLEM:
When did you first notice the problem?*
Describe the earliest incident you can recall:*
Describe the most recent episode (include approximate date):*
Please describe several representative episodes. Include details such as your cat’s posture (ears up or back? tail up or down? tail wagging or flicking? hair puffed? crouched or upright). Describe any vocalization (growl / hiss?).
Episode 1: Include date
Episode 2: Include date
Episode 3: Include date
Has the frequency of the behavior*

IncreasedDecreasedUnchanged
Has the intensity of the problem*

IncreasedDecreasedUnchanged
Why did you decide to seek the advise of a veterinary behaviorist?*
Select any household changes that occurred within 3 months of the onset of the problem:*

New pet in houseLoss of pet in houseIllness of pet in houseNew family memberLoss of family memberPregnancyillness of family memberchange of employment status: new locationchange of employment status: new scheduleOther
If other please describe:
What measures have you taken to manage the behavior?*
How do you generally discipline your cat, and how does (s)he respond?*
Please subjectively rate your perception of the main behavior problem: *

1

2

3

4

5

1 is not serious: I am just curious about the behavior, 5 is not tolerable: I may euthanize my cat if the behavior persists
1. not serious: I am just curious about the behavior

2. nuisance but tolerable

3. serious but I would keep my cat if the behavior persists

4. not tolerable: I may give my cat away if the behavior persists

5. not tolerable: I may euthanize my cat if the behavior persists
Please briefly describe any additional behavioral problems or concerns you experience with your cat:
Aggression Survey - cat

Please answer the following questions if your cat has bitten a person
Indicate the age of your cat and circumstances surrounding the first bite:
How many bites required medical attention?
Who was bitten?
Which of the following has your cat bitten:

handsarmslegsfacechestbuttocks
Is your cat's aggression predictable?

yesno
Do the attacks appear unprovoked?

yesno
Is your cat docile afterward?

yesno
Is your cat disoriented afterward?

yesno
Does your cat appear sorry afterward?

yesno
Do you notice a glazed expression?

yesno
Please select your cat’s response to the following:
To cats seen outside the window:*

ignorehissgrowlurinaterun awayother
To being brushed:*

purrgrowlhissbitetolerates itloves itswats
To being petted by family*

purrbitegrowlhissswattolerates itloves it
To being held in arms or lap:*

purrbitestrugglerest quietlyhiss
Describe your cat’s behavior toward visitors to your home:
familiar visitors*

agressivefriendlyhidesshy
unfamiliar visitors*

agressivefriendlyhidesshy
children*

agressivefriendlyhidesshy
Under what circumstances does your cat meow?*
Under what circumstances does your cat hiss?*
Under what circumstances does your cat growl?*
Does your cat mount people, other animals, or inanimate objects?*
What is it like to medicate your cat? easy-pop in the mouth / hide the meds / never tried / NO WAY!*
AGGRESSION SCREEN for cats
(N/R=NO REACTION; N/A=NOT APPLICABLE)
Pet cat*

NRHissGrowlSwatBiteNA
Lift cat to hold*

NRHissGrowlSwatBiteNA
Approach / pet while resting*

NRHissGrowlSwatBiteNA
Lift off furniture or counter*

NRHissGrowlSwatBiteNA
Approach or touch while eating*

NRHissGrowlSwatBiteNA
Take toy or coveted object*

NRHissGrowlSwatBiteNA
Approach when cat is near his/her special person*

NRHissGrowlSwatBiteNA
Enter or leave room*

NRHissGrowlSwatBiteNA
Stare at cat*

NRHissGrowlSwatBiteNA
Speak to cat*

NRHissGrowlSwatBiteNA
Verbally punish*

NRHissGrowlSwatBiteNA
Physically punish*

NRHissGrowlSwatBiteNA
Put leash, harness or collar on*

NRHissGrowlSwatBiteNA
Trim nails*

NRHissGrowlSwatBiteNA
With veterinarian*

NRHissGrowlSwatBiteNA
With groomer*

NRHissGrowlSwatBiteNA
Unfamiliar visitor enters house*

NRHissGrowlSwatBiteNA
Unfamiliar visitor pets cat*

NRHissGrowlSwatBiteNA
Familiar visitor enters house*

NRHissGrowlSwatBiteNA
Familiar visitor pets cat*

NRHissGrowlSwatBiteNA
Litter Box Information
How did you litter train your cat?*
How often does your cat urinate outside the litter box? Never / rarely / sometimes / often / most of the time (list locations used)*
How often does your cat defecate outside the litter box? Never / rarely / sometimes / often / most of the time (list locations used)*
Please describe the number, type (e.g. hooded, open), and locations of litter boxes in your home:*
When did you last change to a new litter box, type, or location?*
What specific brand and type of kitty litter do you use?*
When did you introduce this litter to your cat?*
How deep is the litter in the litter box? *
Do you use a liner in the box?*
How often do you scoop clumps or feces?*
How often do you dump entire contents of box?*
How often do you wash the litter box?*
What type of cleaner do you use?
Does your cat scratch to cover his urine and / or feces with litter? *
Does your cat scratch inside or just outside the box? *
** If your cat is housesoiling, please supply a sketch of the floor plan of your house. Note windows, doors, and the location of all scratching posts and litter boxes. Please mark any areas of inappropriate elimination with an X.

Photos of the home environment, particularly litter boxes, areas of inappropriate elimination, and favorite resting places are very helpful. They can be emailed prior to the appointment to behavior@centralpetvet.com.
Medical History - Dog
Is your dog spayed or neutered*

YesNo
If yes, what age was the surgery performed
Reason for surgery*

RoutineAttempt to motify behavior
Were there any behavioral changes after the surgery?

YesNo
Provide dates for most recent vaccinations:
Rabies*

MonthDayYear
Date
Distemper/Parvo*

MonthDayYear
Date
Leptospirosis

MonthDayYear
Date
Lyme

MonthDayYear
Date
Other Vaccine?

MonthDayYear
Date
List Other vaccine
What products, if any, do you use for heartworm prevention and flea and tick prevention?*
List current medical conditions, medications and dosages*
List prior medical conditions, medications and dosages:*
Background Information - Dog
Date you adopted your dog*

MonthDayYear
Date
Age at time of adoption*
days, weeks, months, years*

daysweeksmonthsyears
Where did you get your dog?*

ShelterRescue groupPet shopProfessional breederOther
Is this your dog's first home?*

YesNo
If no, how many previous owners.
Do you know why he/she was given up?
Which traits describe your pet as a puppy?*

FriendlyOutgoingShyFearfulAgressivePlayful
Please indicate the reason you decided to adopt this dog:*

CompanionshipShowProtectionOther
Is this your first dog?*

YesNo
How did you select this particular dog over the others?*
Describe the temperament of your dog's mother and father: friendly, shy, aggressive, NA. Please provide pedigree if available.*
Do you know the status of your dog's littermates?*
Home Environment- Dog
Describe your home*

Single family homeApartmentTownhomeTrailerOther
Have you relocated since owning this dog?*

YesNo
If yes, please list the approximate date of move
Please list all members of your household: (NAME, AGE (Children), HOURS AWAY FROM HOME)*
Example: Jane, 12 years old. Tom 20 years old, 1 hour away.
Please list all household pets in order adopted:*
Example: Fluffy 1/1/2010, Puff 2/2/2012...
Describe your dog’s relationship to the other household pets:*
Management - Dog
What % of the day does your dog spend indoors?*
Do you have a fenced yard?*

YesNo
Does your dog run unsupervised outdoors*

YesNo
How often do you walk your dog?*
How does your dog behave when you prepare to take him for a walk?*

comes eagerlyneutralhidesgrowls
How does your dog behave when you prepare to take him for a car ride?*

comes eagerlyneutralhidesgrowls
Where does your dog sleep at night?*
Who wakes up first*

YouYour dog
Where is your dog’s favorite resting spot when you are home?*
Does your dog rest on your furniture?*

oftensometimesnever
Describe your dog’s favorite toys:*
Describe any interactive games that you play with your dog and note frequency:*
How often do you brush your dog?*

dailyweeklyOccasionallyNever
How often does your dog groom himself?*

OccasionallyExcessively
Does your dog usually follow you from room to room?*

YesNo
Does your dog have free access to the house when you leave?*

YesNo
If NO, describe type of confinement: crate / gate / closed door / tie / other
How does your dog behave when you prepare to leave home?*

No reactionLooks sadhidespantspacessalivateswhines
How does your dog behave when you return home?*

No reactiongreetsBrief excitementexcited for >10 minuteshides
Which of the following does your dog chew or scratch:*

clothingtrashdoorswindow framesremotesfurniture
What specific brand and type of food do you feed your dog?*
How long have you been feeding this diet?*
Number of meals per day:*
Which family members are responsible for feeding?*
Location of food bowl(s):*

KitchenLaundryBasementOther
When does your dog eat “table food”?*

special occasionsafter you have eatenwhile you eatnever
What are you dog's favorite treats?*
Please describe your dog’s overall activity level:*

ExcessiveHighModerateLowVery Low
Please describe a typical 24-hour day in the life of your dog*
Behavioral Details - Dog
Briefly describe the PRIMARY behavioral concern. Focus on the single most significant issue—additional concerns can be noted later in the form.*
Describe a typical episode:*
The behavior occurs: ___ times per day / week / month*
PLEASE ANSWER THE FOLLOWING QUESTIONS FOR THE MAIN PROBLEM:
When did you first notice the problem?*
Describe the earliest incident you can recall:*
Describe the most recent episode (include approximate date):*
Please describe several representative episodes. Include details such as your dog’s posture (tail, ears) and any vocalization such as barking or growling.
Episode 1: Include date
Episode 2: Include date
Episode 3: Include date
Has the frequency of the behavior*

IncreasedDecreasedUnchanged
Has the intensity of the problem*

IncreasedDecreasedUnchanged
Why did you decide to seek the advise of a veterinary behaviorist?*
Select any household changes that occurred within 3 months of the onset of the problem:*

New pet in houseLoss of pet in houseIllness of pet in houseNew family memberLoss of family memberPregnancyillness of family memberchange of employment status: new locationchange of employment status: new scheduleNoneOther
If other please describe:
What measures have you taken to manage the behavior?*
Please subjectively rate your perception of the main behavior problem: *

1

2

3

4

5

1 is not serious: I am just curious about the behavior, 5 is not tolerable: I may euthanize my cat if the behavior persists
1. not serious: I am just curious about the behavior

2. nuisance but tolerable

3. serious but I would keep my cat if the behavior persists

4. not tolerable: I may give my cat away if the behavior persists

5. not tolerable: I may euthanize my cat if the behavior persists
Please briefly describe any additional behavioral problems or concerns you experience with your dog:
Aggression Survey - Dog

Please answer the following questions if your dog has bitten a person
Indicate the age of your dog and circumstances surrounding the first bite (or say NA):*
How many bites required medical attention?
Who was bitten?
Which of the following has your dog bitten:

handsarmslegsfacechestbuttocks
Is your dog's aggression predictable?

yesno
Do the attacks appear unprovoked?

yesno
Is your dog docile afterward?

yesno
Is your dog disoriented afterward?

yesno
Does your dog appear sorry afterward?

yesno
Do you notice a glazed expression?

yesno
Describe your dog’s behavior toward visitors to your home:
Familiar visitors*

growlsbarkssnaps or bitesfriendlyshyhides
Unfamiliar visitors*

growlsbarkssnaps or bitesfriendlyshyhides
Children*

growlsbarkssnaps or bitesfriendlyshyhides
Please indicate the most appropriate response to the following statements:
My dog mounts*

household adultshousehold childrenguestsNA
This behavior occurs mainly during:*

playwhen scoldedduring greetingsOther
My dog mounts other animals or inanimate objects*

OftenOccasionallynever
My dog jumps up on family members or others without permission*

OftenOccasionallynever
My dog paws at family members*

OftenOccasionallynever
My dog barks at family members*

OftenOccasionallynever
My dog barks excessively*

YesNo
Training - Dog
How many weeks were required to house train your dog?*
Was a crate used?*

YesNo
How often does your dog urinate or defecate indoors in unacceptable locations?*

oftenoccasionallynever
How do you generally discipline your dog, and how does he or she respond?*
Which training classes has your dog attended? Include name of class, age of dog at time, name of trainer, group or private classes, purpose of the training, and if you were satisfied with your dog's progress.*
example: Puppy Manners, 4 months old, Jane Smith, group class, learn basic commands, I was satisfied.
Has your dog earned any show, obedience or other working titles?*
What type of training collars do you use?*

flat bucklemartingalechokeprongelectronichead halterharness

AGGRESSION SCREEN for Dogs

Terms of Service and Consent
I, as the responsible individual for the animal described above, grant Dr. Jessica Beckstrom permission to prescribe and provide treatment for him/her. I understand that while treatment may be beneficial, there are no guarantees regarding the outcomes. I acknowledge that there are inherent risks in addressing behavioral problems in animals, including potential property damage or the possibility of mental or physical harm to myself or others. I accept these risks. I agree to release Dr. Beckstrom and Central Hospital for Veterinary Medicine from any liability for damages, injuries, death, or other issues that may arise in connection with the treatment of the animal.

I, the undersigned, do hereby consent and agree that a summary of this visit will be sent to my primary veterinarian, and any other veterinarians I have specified.
Signature*

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I hereby consent and agree that Central Hospital for Veterinary Medicine, its employees, or agents have the right to take photographs and / or videotape during this behavior consultation, and to use these images in print of electronic format for the primary purpose of maintaining documentation for my pet’s medical record and a secondary purpose of providing education for veterinarians, students, and the public. My name and identity will not be directly revealed therein.*

I consentI do not consent
Please verify that you are human*
Should be Empty:

	Sit	Down	Come	Stay	Don't Pull
Adult 1
Adult 2
Child 1
Child 2
Child 3
Child 4
Other

	No response	Hides	Follows me	Paces	Whines	Growls	Barks	Chases
Thunderstorm
Rain
Wind
Fireworks
Loud Conversation
Telephone
Sudden noise (drop a metal item)
Vacuum

	No response	snarl	growl	snap	bite	bark	NA
Pet dog
hug or kiss dog
Lift dog
Approach pet while resting
Approach on furniture
Call off furniture
Pull off furniture
Approach while eating
Touch While eating
Take dog food dish
Take water dish
Take human food or treat
Take rawhide or bone
Approach when has bone
Taje toy or coveted object
Approach when dog is near special person
Enter or leave room
Stare at dog
Speak to dog
Visually threaten dog
Verbally punish
Physically punish
Give command to sit or down
Push into sit or down
Push on shoulders or rump
Restrain by leash
Restrain by collar
Put on leash or collar
Remove leash or collar
Reach for dog
Step over dog
Towel dry
Brush
Bathe
Trim nails
With veterinarian
With groomer
Unfamiliar adult/child enters house/yard
Unfamiliar dog enters house/yard
Familiar adult/child enters house/yard
On leash- person approaches
On leash- dog approaches
In house- people or dog pass
In car- toll booth or gas station
Response to infant or toddler
Response to squirrel or cat

Behavior History Form

Client Information

Patient Information

Medical History - Feline

Background Information - cat

Home Environment- Cat

Management

Behavioral Details - cat

Aggression Survey - cat

AGGRESSION SCREEN for cats

Litter Box Information

Medical History - Dog

Background Information - Dog

Home Environment- Dog

Management - Dog

Behavioral Details - Dog

Aggression Survey - Dog

Training - Dog

AGGRESSION SCREEN for Dogs

Terms of Service and Consent