Behavior History Form

  • Behavior History Form

  • Client Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Patient Information

  • Date of Birth*
     - -
  • Gender*
  • Format: (000) 000-0000.

  • Medical History - Feline

  • Is your cat spayed or neutered*
  • Reason for surgery*
  • Were there any behavioral changes after the surgery?
  • Is your cat declawed?*

  • Provide dates for most recent vaccinations:

  • Rabies*
     - -
  • Feline Distemper*
     - -
  • Feline Leukemia*
     - -
  • Other
     - -

  • Background Information - cat

  • Date you adopted your cat*
     - -
  • Days, weeks, months, years*
  • Where did you get your cat?*
  • Is this your cat's first home?*
  • Which traits describe your pet as a kitten?*
  • Please indicate the reason you decided to adopt this cat:*
  • Is this your first cat?*

  • Home Environment- Cat

  • Describe your home*
  • Have you relocated since owning this cat?*

  • Management

  • Does your cat run unsupervised outdoors?*
  • Do you have an outdoor containment system (“cat fence”)?*
  • Who wakes up first*
  • Does your cat usually follow you from room to room?*
  • Does your cat have free access to the house when you leave?*
  • How does your cat behave when you prepare to leave home?*
  • How does your cat behave when you return home?*
  • Does your cat use a scratching post?*
  • Location of food bowl(s):*
  • Describe your cat’s reaction to thunderstorms:*
  • Please describe your cat’s overall activity level:*

  • Behavioral Details - cat

  • PLEASE ANSWER THE FOLLOWING QUESTIONS FOR THE MAIN PROBLEM:

  • 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?).  

  • Has the frequency of the behavior*
  • Has the intensity of the problem*
  • Select any household changes that occurred within 3 months of the onset of the problem:*

  • 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

  • Aggression Survey - cat

    Please answer the following questions if your cat has bitten a person
  • Which of the following has your cat bitten:
  • Is your cat's aggression predictable?
  • Do the attacks appear unprovoked?
  • Is your cat docile afterward?
  • Is your cat disoriented afterward?
  • Does your cat appear sorry afterward?
  • Do you notice a glazed expression?

  • Please select your cat’s response to the following:

  • To cats seen outside the window:*
  • To being brushed:*
  • To being petted by family*
  • To being held in arms or lap:*

  • Describe your cat’s behavior toward visitors to your home:

  • familiar visitors*
  • unfamiliar visitors*
  • children*

  • AGGRESSION SCREEN for cats

  • (N/R=NO REACTION;  N/A=NOT APPLICABLE)

  • Pet cat*
  • Lift cat to hold*
  • Approach / pet while resting*
  • Lift off furniture or counter*
  • Approach or touch while eating*
  • Take toy or coveted object*
  • Approach when cat is near his/her special person*
  • Enter or leave room*
  • Stare at cat*
  • Speak to cat*
  • Verbally punish*
  • Physically punish*
  • Put leash, harness or collar on*
  • Trim nails*
  • With veterinarian*
  • With groomer*
  • Unfamiliar visitor enters house*
  • Unfamiliar visitor pets cat*
  • Familiar visitor enters house*
  • Familiar visitor pets cat*

  • Litter Box Information

  • ** 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*
  • Reason for surgery*
  • Were there any behavioral changes after the surgery?

  • Provide dates for most recent vaccinations:

  • Rabies*
     - -

  • Background Information - Dog

  • Date you adopted your dog*
     - -
  • days, weeks, months, years*
  • Where did you get your dog?*
  • Is this your dog's first home?*
  • Which traits describe your pet as a puppy?*
  • Please indicate the reason you decided to adopt this dog:*
  • Is this your first dog?*

  • Home Environment- Dog

  • Describe your home*
  • Have you relocated since owning this dog?*

  • Management - Dog

  • How does your dog behave when you prepare to take him for a walk?*
  • Does your dog rest on your furniture?*
  • How often does your dog groom himself?*
  • Does your dog usually follow you from room to room?*
  • Does your dog have free access to the house when you leave?*
  • How does your dog behave when you prepare to leave home?*
  • How does your dog behave when you return home?*
  • Location of food bowl(s):*

  • Behavioral Details - Dog

  • PLEASE ANSWER THE FOLLOWING QUESTIONS FOR THE MAIN PROBLEM:

  • Please describe several representative episodes. Include details such as your dog’s posture (tail, ears) and any vocalization such as barking or growling.

  • Has the frequency of the behavior*
  • Has the intensity of the problem*
  • Select any household changes that occurred within 3 months of the onset of the problem:*

  • 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

  • Aggression Survey - Dog

    Please answer the following questions if your dog has bitten a person
  • Which of the following has your dog bitten:
  • Is your dog's aggression predictable?
  • Do the attacks appear unprovoked?
  • Is your dog docile afterward?
  • Is your dog disoriented afterward?
  • Does your dog appear sorry afterward?
  • Do you notice a glazed expression?

  • Describe your dog’s behavior toward visitors to your home:

  • Familiar visitors*
  • Unfamiliar visitors*
  • Children*

  • Please indicate the most appropriate response to the following statements:   

  • My dog jumps up on family members or others without permission*
  • My dog paws at family members*
  • My dog barks at family members*
  • My dog barks excessively*

  • Training - Dog

  • How often does your dog urinate or defecate indoors in unacceptable locations?*
  • What type of training collars do you use?*
  • Rows
  • Rows

  • AGGRESSION SCREEN for Dogs

  • Rows

  • Avian Medical History

  • Where did you acquire your bird?
  • Describe your home:
  • Is the bird’s cage covered at night?

  • Avian Diet

  • Rows
  • Is bird picky about food?

  • Avian Behavior

  • Rows

  • For example: Instead of saying, “Chester is an awful bird. He gets very angry and bites when my father reaches for him,” try saying, “When my father reaches for Chester, Chester’s pupils become very small, the feathers on the back of his neck are raised, he leans back, lunges forward with his beak open, and bites then quickly releases.”

  • Rows

  • Prior to your appointment, please provide photos of your bird’s cage and/or main living space as well as any play areas or other spaces where your bird spends their time. You can email the photos to behavior@centralpetvet.com.

  • 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.

  • 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.*
  • Should be Empty: