CAT HISTORY FORM You can download this form in Word format by clicking here and fill it out offline. Please fill out this form to the best of your ability. The more information that you are able to provide us about your cat's behavior, the easier it is to correctly diagnose your cat's behavior problem and provide you with the proper personalized treatment plan. YOUR INFORMATION First Name: Last Name: Address: City: State: Your e-mail Address: Your Telephone Number: How were you referred to us? YOUR VETERINARIAN First Name: Last Name: Hospital Name: Address: City: State: Telephone: Fax: E-mail: YOUR CAT 1. What is your cat's name? 2. How old is your cat? 3. How much does your cat weigh? 4. What is the breed of your cat? 5. Does your cat have short, medium, or long hair? 6. What color is your cat? 7. Is your cat a male or female? Male Female 8. Is your cat neutered (spayed or altered?) Yes No 9. If yes, how old was your cat when he/she was neutered? 10. Why did you neuter your cat? 11. Where did you get your cat? 12. How old was your cat when you obtained him/her? 13. For how long have you owned your cat? 14. Is your cat declawed? Yes No 15. If yes, how old was your cat when he/she was declawed? 16. Why did you choose this kind (breed) of cat? 17. Why did you choose your individual cat? 18. Does your cat have any medical problems? Yes No 19. If yes, please list what they are and when they occurred. 20. Is your cat being treated for any medical problem at this time? Yes No 21. If yes, is your cat on any medication? 22. Do you know anything about your cat's parents or relatives? 23. If yes, did they have any medical problems? What were they? 24. Did they have any behavioral problems? What were they? YOUR HOUSEHOLD 1. Please list all of the people who live in your house with your cat and their ages. 2. Have you owned pets before? If yes, what kind? 3. When did you own the other pets? 4. Did you grow up with pets? If yes, what kind? 5. Did the other pets have behavior problems? If yes, what kind? 6. What happened to your other pets? 7. Please list all of the animals who live in your house: (Name, species (dog, cat, etc.), breed, sex, neuter status, age, when/where obtained, order obtained) 8. What kind of home do you have? (house, apartment, town house) 9. How big is your home? 10. Is your cat allowed in all parts of your house? If not, where is your cat allowed? PERSONAL CAT CARE 1. What do you feed your cat? (canned, dry, combination) 2. When do you feed your cat? 3. Who feeds your cat? 4. What brand of food do you feed? 5. Does your cat get treats? If yes, what kind 6. Does your cat go outside? If yes does he/she roam free? 7. Is your cat walked on a leash? If yes, what kind of restraint device do you use (collar, harness)? 8. If your cat goes outside, how many hours does he/she spend outside? 9. How many hours is your cat alone without people? LITTER BOX CARE AND HABITS 1. How many litter boxes do you have now? 2. Where are they? (In what rooms and where in the room) 3. What kind of litter boxes do you have? 4. Do they have hoods? 5. How big are they? 6. What is their shape? 7. What kinds of litter boxes have you used in the past? 8. When did you use each one? 9. For how long? 10. Why did you change the kind of litter box you used in the past? 11. What kind of litter do you use right now? Is it scented? 12. Is it clumpable? Yes No 13. What brand of litter do you use right now? 14. What kinds of litters have you used in the past? 15. When did you use each one? 16. For how long? 17. Why did you change the type of litter you were using? 18. Do you add anything to your litter? 19. How often do you scoop the feces from your litter box now? 20. How often do you scoop the urine from your litter box now? 21. Have you always scooped this often? If not, how often did you scoop in the past? 22. Why did you change the frequency of scooping? 23. How often do you add fresh litter to your box? 24. Have you always done this? If not, how often did you add fresh litter in the past? 25. Why did you change the frequency of adding fresh litter? 26. How often do you completely change the litter? 27. Have you always done this? If not, how often did you change the litter completely in the past? 28. Why did you change the frequency of completely changing the box? 29. How much litter do you put in the boxes? 30. Have you always done this? If not, how much did you put in the box in the past? 31. Why did you change the amount of litter you put in the box? 32. Do you use liners? If yes, what kind? 33. What brand? 34. Why do use liners? 35. Have you always used liners? If not, why did you decide to use them? 36. Have you ever seen or heard your cat in the litter box? If yes, does your cat dig in the litter? 37. Does he/she scratch some litter outside of the box? Yes No 38. Does your cat scratch the sides of the box? Yes No 39. Does your cat scratch outside of the box? (floor, etc) Yes No 40. Does your cat spend as little time in the box as possible and immediately jump out of the box after urinating or defecating? Yes No 41. Does your cat cover his/her urine most of the time? Yes No 42. Does your cat cover his/her feces most of the time? Yes No 43. How often does your cat urinate? (times per day) 44. How often does your cat urinate inside of the box? 45. How often does your cat urinate outside of the box? 46. If your cat urinates outside of the box, where do you find it? 47. Do you find large amounts of urine or small amounts? (outside the box) 48. Do you find the urine on horizontal surfaces (floors) or vertical (walls) surfaces? 49. Have you seen your cat scratch the surface before urinating? Yes No 50. Have you seen your cat scratch the surface after urinating? Yes No 51. How often does your cat defecate? (times per day) 52. How often does your cat defecate in the box? 53. How often does your cat defecate outside of the box? 54. If your cat defecates outside of the box where do you find it? 55. Have you seen your cat scratch before defecating? 56. Have you seen your cat scratch after defecating? THE PROBLEM 1. What is your cat doing that is a problem to you? 2. Does your cat have any other behavior problems? 3. What happened that made you decide to seek help? 4. When was it? 5. What happened before the incident? 6. How did you respond after the incident? 7. How did your cat respond? HISTORY/DEVELOPMENT OF THE PROBLEM AND CORRECTIONS ATTEMPTED 1. How long have you and your cat had this problem? 2. When was the first time you noticed that your cat had the problem? 3. How old was your cat when you noticed that your cat had this problem? 4. Describe in detail the very first episode of the problem 5. When was it? 6. What time of day? 7. What happened before? 8. What did you do after it occurred? 9. What did your cat do after it occured? 10. Describe in detail another early episode of the problem. 11. When was it? What time of day? 12. What happened before? 13. What did you do after it occurred? 14. What did your cat do after it occured? 15. Tell us everything that you have done to try to correct the problem you are having. *Include the dates of all attempted corrections, how long you tried and how your cat responded (no better, somewhat better, much better). 16. Has your cat been on any medications for the problem? If yes, what types? When? For how long? What dosage? DETAILED DESCRIPTIONS OF RECENT INCIDENTS Describe in detail the most recent episode of the problem: 1. When was it? What time of day? 2. What happened before? 3. What did you do after the episode? 4. How did your cat respond? Describe in detail the next to last episode of the problem: 5. When was it? What time of day? 6. What happened before the incident? 7. What did you do after the incident? 8. How did your cat respond? Describe in detail the third to last episode of the problem: 9. When was it? What time of day? 10. What happened before the incident? 11. What did you do after the incident? 12. How did your cat respond? 13. How often does the problem occur? (times per day, per week, per month) 14. Does the problem happen more often now than when it started? If yes, please describe. 15. Was the increase gradual or sudden? 16. Is the problem worse in severity/intensity since it started? If yes, please describe. 17. How often do your cat's other problems occur? (times per day, week or month) 18. Does the problem happen more often now that when it started? If yes, please describe. 19. Was the increase gradual or sudden? 20. Is the problem worse in severity/intensity since it started? If yes, please describe. 24 HOUR DAY IN THE LIFE OF YOUR CAT AND YOU Where does your cat sleep at night? Starting with when both of you get up: Please indicate when you feed your cat, who feeds your cat, when you play with your cat, who plays with your cat, when you pet your cat, when your cat interacts with other animals, when your cat urinates and defecates, when your cat is left alone, when your cat goes outside, when you are likely find evidence of the behavior problem. 4-am 5-am 6-am 7-am 8-am 9-am 10-am 11-am 12-pm 1-pm 2-pm 3-pm 4-pm 5-pm 6-pm 7-pm 8-pm 9-pm 10-pm 11-pm 12-am 1-am 2-am 3-am AGGRESSION SCREEN 1. Has your cat ever bitten a person? If yes, who was it? Describe the incident in detail. 2. When was it? 3. What happened before? 4. What did you do after? 5. How did your cat respond? 6. Did the bite break the skin? 7. Did it require medical treatment? If yes, what kind? (hospital, antibiotics) 8. Was the bite reported? 9. Was your cat quarantined? 10. Has your cat ever bitten another animal? If yes, who was it? Describe the incident in detail. 11. When was it? 12. What happened before? 13. What did you do after? 14. How did your cat respond? 15. Did the bite break the skin? 16. Did it require medical treatment? If yes, what kind? (hospital, antibiotics) 17. Was the bite reported? 18. Was your cat quarantined? Has your cat ever growled, hissed, swatted, scratched or bitten: 19. A household cat? (who?) Describe: 20. An outdoor cat? Describe: 21. Other animals? Describe: People: 22. While being petted? Describe:(indicate who) 23. When picked up? Describe:(indicate who) 24. Was the aggressive incident preceded by a stalk or chase? If yes, where did it occur? Indicate who? 25. How does your cat act when examined by your veterinarian? 26. How does your cat act when groomed, either by you or the groomer? 27. Can you trim your cat's nails? 28. Can you give your cat a pill? 29. Describe how your cat acts when visitors come to your house. (include attitude toward visitors when you are not home: cat sitters) ATTACHMENT On a scale of 1 to 10, How serious is each problem to you and to each family member? 1 being not at all serious and 10 being the most serious: 1. Main problem: 2. Other problems 3. Have you considered getting rid of your cat? Why have you not done so? (this question does not mean we are recommending this) 4. Have you considered putting your cat to sleep? (this question does not mean we are recommending this) Why have you not done so? ALL CLIENTS RECEIVE A FREE LIFETIME SUBSCRIPTION TO OUR ONLINE MAGAZINE "Pet-Lines". Please enter the username and password you would like: Username: Password: If you are uncomfortable providing your credit card information on the web, please call us and we'll take your information by phone (781) 862-5060. Copyright 1999-2006, Petbehaviorproblems.com