Case Review - Feline Behavioral History

Behavior Assessment - Feline

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Overview
Individual completing this form. *

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Pet's name*
Pet's approximate age or date-of-birth, sex, spay/neuter status, breed or breed mixture, & most recent weight. *
Ex: 2 year old, neutered male, DSH, 9 lbs.
Photograph of pet*

Cancelof
Veterinary Clinic, Doctor, and Telephone Number*
Consent to Use Medical Information for Professional Development

I hereby consent to the disclosure of my pet's medical and behavioral information to Mindful Mentor Behavior Consulting, LLC. for the purpose of discussing their condition with verified veterinary professionals. My personal information such as full name, address, and telephone number will NOT be used during this discussion, but my pet's identifying information will be. I understand that all participants in the webinar are required to sign a confidentiality clause preventing them from using this information without written consent from me. I have the right to withdraw my consent at any time. This consent is valid for 90 days from time of signing.
Signature
Today's date
Acquisition & Early History
How did you acquire this cat?*

BreederShelterRescueFriend or family memberFound it/strayOther
What is the pet's history prior to acquisition?*
Approximate date and age of acquisition?*
If spayed or neutered, at what age was it performed?
How much interaction did this cat have with people and other animals during their first year of life?*
Briefly describe your pet's personality. *
Describe the problem(s) you are currently having. *
When did this start?*
What has been tried to correct the problem?*
Do you suspect any cause?*
Describe the last three incidents or episodes. *
Describe the cat's body posture during these episodes. *
What was your (or your family's) response to these episodes?*
What was your cat's reaction to your response?*
If there were aggressive behaviors, what was the result to the victim? (Check all that apply)*

Not applicableNo contact, just posturingBruiseScratchShallow puncture (Less than 0.5 inches deep)Deep puncture (Greater than 0.5 inches deep)TearingRequired medical treatmentOther
Are there any other pertinent details or comments you would like to share? *
Medical History
What do you feed your cat? Please provide name/formula, quantity fed, frequency of feeding, & crude protein percentage on the bag. *
Ex: Science Diet Adult Small Bites - 1/3 cup twice daily.
How would you describe your cat's appetite? Select all that apply.*

Poor, very pickyGood, eats normallyVoracious, always eatingConsistentSporadic

Please provide information about any routine products, medications, or supplements:

Rows	Name/Description	Amount/Dose	Frequency	Comments or Response
Preventatives
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10

Please provide details about any chronic medical conditions your cat has, including diagnosis & treatment.
From the list below, please check any ailments your pet has experienced within the last year.*

CoughingSneezing (excessive)Eye dischargeNose dischargeVomiting or regurgitationDiarrhea or soft stoolLameness or limpingChanges in activity levelSeizuresSurgery (besides spay/neuter, if applicable)None of the aboveOther
Does your pet have a relationship with any of the following veterinary specialists?*

Internal MedicineSurgery/OrthopedicsRehabilitation/Physical TherapistChiropractor and/or AcupuncturistOphthamologistDermatologistOncologistBehavioristOtherNot Applicable
If you selected any of the above, please provide their name, facility, and telephone number.
Household & Daily Life

Please list the human occupants living in your home, whether part or full time. *

Rows	Name	Age	Occupation	Relation to you	Relationship (how they get along) with this cat
Yourself
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10

Please list any other pets or animals living in your home, excluding the patient.

Rows	Name	Age	Sex, spay/neuter status	Species & Breed	Relationship (how they get along) with this cat
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10

In what sort of home do you and your pet reside?*

Single Family HomeTownhouseCondo/ApartmentOther
How would you describe the energy in your home?*

Quiet, slow, routine orientedModerate activity, some sporadic changesHigh activity, lots of coming & going, noisy
Have you owned a cat in your adult life prior to this one?*

YesNo
How do you feed your cat?*

Out of a bowlFeeder toysPuzzle toysAs part of trainingHiding around the house
Where does your cat eat in relation to other pets in the household?
Do you need to be present for your cat to eat?*

YesNoSometimes
Where does your cat spend most of their day?*
Where does your cat sleep at night?*
In a 24 hour period, how much does your cat sleep?*
Is your cat allowed outside?

No - NeverYes - Always supervised on my deck, porch, yard, etc.Yes - We go for leash or stroller walksYes - Unsupervised
If applicable, how much time does your cat spent outside each day?
Do you have a yard? If yes, check all that apply:*

YesNoUnfencedSee through fencing (picket, wire, etc.)Privacy fencingSmall (Less than 0.25 acres)Medium (0.25 - 1 acre)Large (Greater than 1 acre)
Is there any time each day dedicated to play or exercise?*

YesNoSometimes
Is your cat playful?*

YesNoSometimes
Is your cat affectionate or cuddly with people in the home?*

YesNoSometimes
Is your cat affectionate or cuddly with visitors to the home?

YesNoSometimes
If you have multiple cats, do you ever see them snuggling or grooming each other?

N/AYesNoSometimes
Does petting (from a human) or grooming (from another cat) ever result in aggressive episodes?

YesNoSometimes
If you have multiple cats, do you ever see one hissing, swatting, and running away from another?

YesNoSometimes
If "yes" or "sometimes" to the above question, please provide more details about what happens, which cats are involved, and how frequently the episodes occur.
Does your cat like to scratch?*

YesNoSometimes
Do they scratch inappropriate items?*

NoYesSometimes
Any inappropriate chewing or consumption of non-food items?*

YesNoSometimes
Any additional details around play, scratching, chewing, etc?
What does your cat do as you prepare to leave?*
Do you record or monitor your pet when they are home alone?*

YesNoSometimes
What is the average length of time your pet might be left home alone?*
Does your cat exhibit any of the following behaviors as you are preparing to leave or once you are gone?*

Pacing and/or panting for extended periods of timeVocalization including whining, crying, meowing, yowlingDestruction of doors, windows, or wallsDamaging inappropriate objectsUrination and/or defecation outside the litterboxExcessive droolingVomitingNone of the above
Training & Learning History
How would you describe your cat's ability to learn?*

PoorAverageExcellent
Is there any specific time devoted to training each day?*

YesNo
Have you ever worked with another behavior specialist or trainer?*

YesNo
If yes to any of the above, please provide some more details below.
How do you correct your cat when they misbehave?*
Any other comments pertaining to training?
Litterbox & Elimination Habits
How many litterboxes do you have?
Is/are your litterboxes covered?

YesNoSome of them are
What type of litter or litter system do you use?
Describe your cleaning routine.
Describe your cat's digging behavior:

Digs before eliminatingDigs after eliminatingDigs in the litterDigs on the walls/sides of the litterboxDigs just outside the litterbox on the floor or walls.None of the above
Do you ever see your cat quickly running from the litterbox after eliminating?

YesNoSometimes
Does your cat ever urinate outside the litterbox?

YesNoSometimes
Does your cat ever defecate outside the litterbox?

YesNoSometimes
Miscellaneous Behaviors

Does your cat demonstrate aggressive behaviors in any of the following circumstances? (Aggression is defined as any "distance increasing behavior" and can include stiffening, staring, growling, swatting, hissing, biting, etc.)

Rows	Primary owner	Co-owner	Children	Other people
Handling/Grooming
Petting/Hugging
Disturbing while resting
Disciplining
Taking away food
Taking away objects

Describe your cat's response in the following situations. Write N/A for situations that do not occur for your cat. *

Rows	Inside the home	Outside the home
Frequent Visitors
Occasional Visitors
Unknown females
Unknown males
Unknown children
Unknown dogs (on leash)
Unknown dogs (off leash)
Crowds/busy areas
Trucks, buses, cars, etc.

Any distress associated noises, storms, or fireworks?*

YesNoSometimesThunderstormsFireworksOther
Does your cat demonstrate any inappropriate sexual behavior?*

YesNo
Is your cat protective of any part(s) of their body?*

YesNo
If yes, what part?
How does your pet behave at the veterinary hospital?
Does your cat ever demonstrate any of the following behaviors?*

Chases lights or reflectionsChases shadowsChases their tail/spinsSuckles on blankets, pillows, beddingExcessively lick themselvesExcessively lick othersExcessively lick other surfacesCause injury to themselves from licking or chewingNone of the above
Are there any other behaviors your find objectionable?
Perspective & Expectations
Using the scale below, how would you rank your cat's overall behavior? 1 meaning the cat needs to be out of the house ASAP and 10 meaning they are perfect and nothing needs changing.*

12345678910
What is the family's thoughts on the current problem(s)?*
What are your goals for treatment? Expectations for change?*
Under what circumstances would you rehome this cat?*
Under what circumstances would you euthanize this cat?*
Any final thoughts, concerns, or topics you would like to discuss?
Should be Empty:

Behavior Assessment - Feline

Overview

Consent to Use Medical Information for Professional Development

Acquisition & Early History

Medical History

Household & Daily Life

Training & Learning History

Litterbox & Elimination Habits

Miscellaneous Behaviors

Perspective & Expectations