Clone of Canine Behavior Questionnaire

Feline Behavior Questionnaire

(This form is adapted from "Manual of Clinical Behavioral Medicine for Dogs and Cats" by Dr. Karen L. Overall and is for the exclusive use of clients of Veterinary Relief and Behavior, LLC)
The more specific information you provide, the better we can help you and your pet! This form will likely take you 30-45 minutes to complete, and can be completed in more than one sitting. You can save your progress and come back to it later by clicking the "SAVE" button at the bottom of the screen. (You do not need to click the save button between sections unless you are taking a break.)

NOTE: If you have multiple pets that you would like behavior consultations on, please fill out a SEPARATE form for each pet. At the end of this form it will give you an option to pre-fill your contact info for your second pet's form. If one of the pets is a dog, then please make sure to use the canine questionnaire on our website. Thank you!
If you want more information about veterinary behavior consultations with Dr. Edwards, go to https://www.tampaveterinarybehavior.com
YOUR Name*

First NameLast Name
Email*
example@example.com
Address – this is where we will meet if doing an in-home consultation.*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number – (CELL phone is preferable so we can text you about your pet)*
Please enter a valid 10 digit phone number.
Name of spouse/partner (if applicable)
Email of spouse/partner (if applicable)
example@example.com
Phone of spouse/partner (if applicable)
Please enter a valid 10 digit phone number.
What is the COMPLETE NAME of the veterinary hospital you take your pet to? (This is where we will request medical records from, and where we will send a copy of your behavior reports.)*
What CITY is this hospital located in?*
There are many animal hospitals with similar names, so this helps us make sure we're contacting the right one!
Who is your pet's primary doctor at that hospital?
We will request medical records for your pet from your veterinarian(s). Are there any OTHER hospitals (besides the one listed above) that have recently treated your pet?
Also, is there any other name (e.g., married name) or phone number that an animal hospital might have your pet's records listed under?
Who referred you to Dr. Edwards?
Date of form completion (i.e., today's date)

MonthDayYear
Date
Your pet's name (REMINDER: if seeking a behavior consultation on MULTIPLE pets, please complete a SEPARATION QUESTIONNAIRE for each pet)*
One pet per form, please
Breed of cat
Cat's gender*
Is this patient neutered/spayed?*
Cat's date of birth:*

MonthDayYear
If not sure, round to nearest year
Check here if date of birth is an estimate
Cat's body weight (in POUNDS)
Date you acquired your cat:*

MonthDayYear
If not sure, round to nearest year
Has this pet had previous owners?*
If previous owners, why was this pet relinquished?
Where did you get this pet?

Stray/found itBreeder (serious show/performance breeder)Breeder (backyard breeder or neighbor)Rescue organization or shelterPet StoreOther
Why did you get this cat?
Does your cat have any medical or physical problems that your veterinarian has noted?
Is your cat currently on any flea/tick prevention or heartworm prevention? If so, which one(s)?*
Is your cat taking any other medications or supplements right now? If so, what doses, how frequently, and for how long?*
Has your cat ever been treated before with any behavioral medications or supplements? If so, please elaborate. What effects did they have?*
What food and what treats (if any), does your cat receive?
Does your cat have any feeding restrictions? (i.e., are there any treats that I should NOT bring to your cat's behavior consultation?) If so, please elaborate.*
Does your cat exhibit periodic diarrhea or gastrointestinal distress (i.e., intermittent stomach upset)? If so, please explain. (NOTE: THIS INCLUDES HAIRBALLS)
Please describe the enrichment your cat gets on an average day. We know this might vary significantly from day to day, but whatever information you can provide could be helpful)
Has your household changed since acquiring this pet?*

Another pet added to the familyFamily movedFamily schedule changed (e.g., change in work schedule from a new job)MarriageBaby was bornChild or family member moved out of/into houseDeath of human in familyDeath of pet in familyDivorceNo changes
If yes, WHEN did EACH of these changes occur?
If you have any UPCOMING changes, what are they and when will they happen?
Were any littermates, parents, or other relatives of this cat known to have any MEDICAL or BEHAVIORAL problems?

Previous pet experience...

	Yes	No
Have you owned CATS before?
Have you owned DOGS before?

Please list ALL the people, INCLUDING yourself, currently living in the household*

	Name	Relation	Gender	Age	Occupation
You
2
3
4
5
6
7
8

Please list all the PETS currently living in the household*

	Name	Species	Gender	Spay/Neutered?	Age	Date joined household
Patient
2
3
4
5
6
7
8

Any special circumstances related to the living situation?
Let us know if a family member or pet is only with you for part of the year, for example.
Do any of the other pets listed above (excluding the primary patient) have previously diagnosed MEDICAL problems? If so, please explain.
Do any of the other pets listed above (excluding the primary patient) have previously diagnosed BEHAVIORAL problems? If so, please explain.

Problem Behaviors
Problem #1a: Please state the MOST important behavioral problem/complaint.*
Problem #1b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?*
Problem #1c: Approximately when did you first notice this problem?*

MonthDayYear
Date
Problem #2a: Please state the second-most important behavioral problem/complaint.
Problem #2b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?
Problem #2c: Approximately when did you first notice this problem?

MonthDayYear
Date
Problem #3a: Please state the third-most important behavioral problem/complaint.
Problem #3b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?
Problem #3c: Approximately when did you first notice this problem?

MonthDayYear
Date
Problem #4a: Please state the fourth-most important behavioral problem/complaint.
Problem #4b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?
Problem #4c: Approximately when did you first notice this problem?

MonthDayYear
Date
Problem #5a: Please state the fifth-most important behavioral problem/complaint.
Problem #5b: How often does this behavior happen? Is there a pattern to when this behavior occurs? Are there certain circumstances where it does NOT occur?
Problem #5c: Approximately when did you first notice this problem?

MonthDayYear
Date

Additional Information
Please review these key points to ensure the best outcome for your pet. Check each box to confirm that you have read them and understand.
Behavioral treatment is a process, not a one-time fix. Most issues are managed over time rather than completely resolved. Success requires ongoing adjustments and follow-up care.*

I understand
Follow-up appointments are essential. The first follow-up is usually 2-3 months after the initial consult. After that, follow-ups will be every 2-12 months (depending on progress, and client communication/updates).*

I understand
In some cases, medications can be a critical part of achieving improvement and reaching your behavior modification goals.*

I understand
Regular updates are key to behavioral management. Medications often need to be adjusted over time. Also, staying in touch can reduce the number of follow-up appointments needed.*

I understand
Is there anything else you think we should know?
What are your goals for this behavior consultation? In other words, what outcome would you like to achieve for your pet?*
Should be Empty:

	Yes	No
Are you concerned that you may have caused the problem(s)?
Do you feel guilty about this problem?
Have you considered finding another home for your cat?
Have you considered bringing your pet to a shelter?
Have you considered euthanasia (putting your pet to sleep)?

	Thunderstorms	Fireworks	Other noises (if applicable)
Hide
Try to Escape
Freeze
Howl
Hiss
Shake
Urinate or Defecate
Pace
Destruction (e.g., chew on things)

	Yes	No	I'm not sure
Wind
Darkness
Rain

	Hiss/howl/growl	Whip tail	Piloerect (puff up)	Swat/Scratch	Bite
Take cat's food dish (w/ food)
Take cat's food dish (empty)
Take human food or other high value food
Take small treat or other low value food
Human approaches cat while eating
Cat approaches cat while eating
Take toy
Human approaches while cat playing w/ toy
Cat approaches while cat playing w/ toy
Human approaches/disturbs cat while sleeping
Cat approaches/disturbs cat while sleeping
Human walks past cat in doorway
Step over cat

	Hiss/howl/growl	Whip tail	Piloerect (puff up)	Swat/Scratch	Bite
Put on collar/harness/shirt
Push cat off bed/couch/surface
Reach toward cat
Pet cat when in lap
Pet cat when NOT in lap
Groom cat
Trim nails
Stranger enters room
Human carries cat
Cat in vet's office
Cat yelled at
Cat physically punished - hit
Human body parts moving under covers on bed

Feline Behavior Questionnaire

Litter Box Habits

Problem Behaviors

Behavioral Concerns

Problem Development

Screening Questions

Noise Screen

Reactivity/Aggression Screen

Previous Treatments

Stereotypic and Ritualistic Behavior - READ INSTRUCTIONS BELOW

Questionnaire for Senior Cats - READ INSTRUCTIONS BELOW

Additional Information

	Yes, CURRENTLY using this technique.	I used this in the past, but not anymore	Never used/tried
Stare at or "stare down"
Hiss or growl at cat
Blow in nose/on face
Throw a tin/can of pennies (i.e., shaker can)
Spray bottle
Yell or scream at cat
Praise for good behavior
Give treats for good behavior
Deprive of food
Shove cat's nose/face into urine/feces/destroyed item
Use scat mats or other electronic avoidance systems
Foghorn
Hit cat with hand
Hit cat with another object

	Yes	No	Unknown
Chewing self
Licking self
Suckling on own skin (e.g., cat holds leg in its mouth but doesn't chew)
Biting self
Plucking hair from self

	Yes	No	Unknown
Staring at and attending to things that are not real
Tracking things that are not real
Pouncing on or attacking things that are not there

	Yes	No	Unknown
Consuming dirt, soil, or rocks
Consuming other objects
Chewing/eating fabric, rugs, clothing, bedding
Licking/suckling (but not chewing) on fabric, rugs, clothing, bedding
Licking or gulping air

	Yes	No	Unknown
Circling/spinning WITHOUT focus on tail
Tail-chasing (with or without grabbing it)

	Yes	No	Unknown
Rhythmic meowing - NOT at any specific object/thing
Rhythmic howling - NOT at any specific object/thing
Rhythmic growling - NOT at any specific object/thing

	More than once a day	Once a day	Once a week	Once a month	Never
Walk in circles, pace, or wander with no direction or purpose?
Stare blankly at the walls or floor?
Get stuck behind objects and is unable to get around them?
Fail to recognize familiar people or pets?
Walk into walls or doors?
Walk away from/avoid being petted or receiving other loving attention they used to enjoy?