Feline Behavior History Form



351028024765Carolina Veterinary Behavior ClinicDr. Jillian Orlando, DVM, DACVB409 Vick AvenueRaleigh, NC 27612 Phone: (919) 791-9058Fax: (919) 324-3822appointments@00Carolina Veterinary Behavior ClinicDr. Jillian Orlando, DVM, DACVB409 Vick AvenueRaleigh, NC 27612 Phone: (919) 791-9058Fax: (919) 324-3822appointments@FELINE BEHAVIORAL HISTORY FORMThis questionnaire is long but is crucial to helping understand your pet’s problem behaviors as well as screen for other potential behavioral problems. Please fill out this form in its entirety and return it to the CVBC by email or fax. NOTE: If your cat is house-soiling, please make a rough sketch of your house layout. Mark the areas in which the house-soiling occurs and the locations of the litter boxes. Send this with the history form or bring it with you to your appointment. CLIENT AND PATIENT INFORMATIONCLIENT INFORMATIONLast Name: FORMTEXT ????? First Name: FORMTEXT ????? Street Address: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Home Phone: FORMTEXT ????? Cell Phone: FORMTEXT ????? E-mail address: FORMTEXT ????? Spouse/Partner First Name: FORMTEXT ????? Last Name: FORMTEXT ?????PET INFORMATIONName: FORMTEXT ????? Breed: FORMTEXT ????? Color: FORMTEXT ????? Date of birth: FORMTEXT ????? Age: FORMTEXT ????? Weight: FORMTEXT ?????Sex: Male (intact) ? Male (neutered) ? Female (intact) ? Female (spayed) ? Age when obtained: FORMTEXT ????? Age neutered or spayed: FORMTEXT ?????Where did you obtain this cat? FORMTEXT ?????BREEDER ? PET STORE ?ANIMAL SHELTER ?RESCUE ? FRIEND ? OTHER FORMTEXT ?????VETERINARY INFORMATIONYour primary veterinarian’s name: FORMTEXT ?????Name of Clinic or Hospital: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Office Phone: FORMTEXT ?????Fax: FORMTEXT ?????How did you hear about the Carolina Veterinary Behavior Clinic? FORMTEXT ?????HOUSEHOLD INFORMATIONPERSONS LIVING IN THE HOUSEHOLDNameAgeSexHours Away from Home Interaction with pet FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????M ? F ? FORMTEXT ????? FORMTEXT ?????PETS LIVING IN THE HOUSEHOLDNameSpeciesBreedAgeSexWeightInteraction with patient pet FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????BEHAVIORAL PROBLEMSPlease list your pet’s top 3 behavioral problems that you would like to address: FORMTEXT ?????How would you describe the severity of this problem? MILD ? MODERATE ? SEVERE ?How often does this problem occur? FORMTEXT ?????Total number of times this has occurred? FORMTEXT ????? FORMTEXT ?????How would you describe the severity of this problem? MILD ? MODERATE ? SEVERE ?How often does this problem occur? FORMTEXT ?????Total number of times this has occurred? FORMTEXT ????? FORMTEXT ?????How would you describe the severity of this problem? MILD ? MODERATE ? SEVERE ?How often does this problem occur? FORMTEXT ?????Total number of times this has occurred? FORMTEXT ?????What are your goals for treatment? FORMTEXT ?????Have you considered euthanasia?YES ?NO ?Please comment: FORMTEXT ?????Describe the worst two incidents in as much detail as possible.Date: FORMTEXT ????? Incident: FORMTEXT ?????Date: FORMTEXT ????? Incident: FORMTEXT ?????PROBLEM BEHAVIOR HISTORYHow old was your pet when the problem(s) began? FORMTEXT ?????Were there changes in the home at that time? FORMTEXT ?????What do you think is the reason for your cat’s problem? FORMTEXT ?????List techniques you have used to address the problem(s). Put (+) next to techniques that seem to have helped.Put (-) next to techniques that made things worse.Put (0) next to techniques that had no effect.1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????List any medication, supplements, or other remedies your pet has received for its behavioral problem(s)? Put (+) next to ones that seem to have helped.Put (-) next to ones that made things worse.Put (0) next to ones that had no effect.1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????PUNISHMENTSIndicate any correction techniques you have used and indicate their effects on your cat’s behavior.TypeHave you Tried?Improved ProblemNo Effect Made WorseCommentsTime outYes ? No ???? FORMTEXT ?????Leash jerksYes ? No ???? FORMTEXT ?????Verbal scolding Yes ? No ???? FORMTEXT ?????NoisemakerYes ? No ???? FORMTEXT ?????Water bottleYes ? No ???? FORMTEXT ?????Spanking/smackingYes ? No ???? FORMTEXT ?????ScruffingYes ? No ???? FORMTEXT ?????Other FORMTEXT ?????Yes ? No ???? FORMTEXT ?????SPECIFIC BEHAVIORAL HISTORY/SCREENINGHANDLINGCheck how your cat responds to the following tasks:TASKNo reactionEnjoysAvoidsResistsGrowls/HissesBitesCOMMENTSPetting head?????? FORMTEXT ?????Stroking along back?????? FORMTEXT ?????Rubbing belly?????? FORMTEXT ?????Being picked up?????? FORMTEXT ?????Being restrained?????? FORMTEXT ?????Brushing?????? FORMTEXT ?????Bathing?????? FORMTEXT ?????Trimming nails?????? FORMTEXT ?????Are you able to medicate your cat yourself? YES ? NO ?What is the best way for you to give your cat medication? FORMTEXT ?????AGGRESSIONAre you having a problem with aggression in your cat? YES ? NO ?If you answered NO, please skip this section and proceed to “FEAR AND ANXIETY.”Who is the target of the aggression? PEOPLE ? OTHER CAT(S) ? BOTH ? Indicate your cat’s response to the following situations. Check all that apply.TaskNo ResponseFreezes/ StaresGrowls/HissesSwatsBitesCommentsWhen cat is approached by a familiar person????? FORMTEXT ?????When cat is approached by an unfamiliar person????? FORMTEXT ?????When cat sees other household cats in house????? FORMTEXT ?????When cat sees a unfamiliar cat outside ????? FORMTEXT ?????When cat sees household dog????? FORMTEXT ?????Ever, to family members????? FORMTEXT ?????Ever, to children????? FORMTEXT ?????To painful stimuli (brushing out mats)????? FORMTEXT ?????Other FORMTEXT ?????????? FORMTEXT ?????Has your pet been reported to animal control authorities or a public health department for biting? YES ? NO ?Is your pet currently in 10-day quarantine for biting? YES ? NO ?BITE HISTORYTYPE OF BITEHas Occurred To a CatTo a Human Total # of IncidentsCOMMENTSSnapped at, no contact??? FORMTEXT ????? FORMTEXT ?????Made contact, no mark??? FORMTEXT ????? FORMTEXT ?????Small red mark??? FORMTEXT ????? FORMTEXT ?????Bruised, no broken skin??? FORMTEXT ????? FORMTEXT ?????Broke skin, minor scrape??? FORMTEXT ????? FORMTEXT ?????Puncture??? FORMTEXT ????? FORMTEXT ?????Multiple punctures??? FORMTEXT ????? FORMTEXT ?????Laceration, torn flesh??? FORMTEXT ????? FORMTEXT ?????Required ER treatment??? FORMTEXT ????? FORMTEXT ?????FEAR AND ANXIETYHow does your cat react to thunderstorms? FORMTEXT ?????How does your cat react to light rain/mild storms? FORMTEXT ?????How does your cat react to fireworks? FORMTEXT ?????Does your cat react fearfully to other loud noises (gunshots, engine backfire, etc)? FORMTEXT ?????Please describe: FORMTEXT ?????Does your cat react fearfully to loud kitchen appliances or the vacuum cleaner? FORMTEXT ?????Does your cat react fearfully to riding in the car? FORMTEXT ?????Does your cat react fearfully to going places (vet’s, groomer)? FORMTEXT ?????Does your cat enter his/her carrier willingly? FORMTEXT ?????What is your cat’s behavior while in the carrier (ex. tries to escape, sleeps, meows, urinates, etc.)? FORMTEXT ????? Please use the following chart to list what anxious behaviors your cat shows during specific situations (including the ones mentioned above):Signs of anxietySituations in which it occursCowering FORMTEXT ?????Trembling FORMTEXT ?????Ears back FORMTEXT ?????Freezing/becoming immobile FORMTEXT ?????Retreating/backing away FORMTEXT ?????Hiding (under bed, behind couch) FORMTEXT ?????Meowing/crying in distress FORMTEXT ?????Panting FORMTEXT ?????Drooling FORMTEXT ?????Please make any additional comments regarding fear or anxiety in your cat: FORMTEXT ?????Describe any situation in which your cat seems fearful and may resort to using aggression: FORMTEXT ?????OTHER PROBLEMS: Check any unwanted behaviors that your cat exhibits.Jumping on counters ?Scratching furniture ?Excessive grooming/chewing ?Excessive night activity ?Excessive meowing ?Stealing/chewing items ?Excessive licking of surfaces ?Describe any unwanted problems in greater detail. FORMTEXT ?????HOUSE-SOILINGAre you having a house-soiling problem with your cat? YES ? NO ?If you answered NO, please skip this section proceed to “HOME ENVIRONMENT AND TRAINING.”House-soiling problem related to: URINE ? FECES ? BOTH ?Have you ever seen your cat spray urine (back up to a surface and emit a small amount of urine while standing? YES ? NO ? UNCERTAIN ?Have you ever seen your cat squat to urinate outside of the box? YES ? NO ? UNCERTAIN ?How often (per day or per week) do you detect urine or feces outside the litter box? FORMTEXT ?????If you have more than one cat, which of your cats is house-soiling? FORMTEXT ?????How do you know this cat is the “culprit”? FORMTEXT ?????In what room or rooms does your cat house-soil? FORMTEXT ?????In what room or rooms (to which your cat has access) does house-soiling NEVER occur? FORMTEXT ?????What is your cat’s favorite “surface” for house-soiling (ex: carpet, throw rugs, bed, laundry, other): FORMTEXT ?????What time of day is your cat most likely to house-soil? FORMTEXT ?????What type/brand of cleaning products have you used to clean soiled areas in the past and currently use? FORMTEXT ?????Do you think this/these products have been effective? FORMTEXT ?????NOTE: If your cat is house-soiling, please make a rough sketch of your house layout. Mark the areas in which the house-soiling occurs and the locations of the litter boxes. Bring the sketch with you to your appointment. LITTER BOX DATALitter Box InformationResponseCommentsNumber of litter boxes in your home FORMTEXT ????? FORMTEXT ?????Location of the litter boxes FORMTEXT ????? FORMTEXT ?????How often are litter boxes scooped out? FORMTEXT ????? FORMTEXT ?????What type of litter box(es) do you use (ex: plain, covered, or electronic)? FORMTEXT ????? FORMTEXT ?????Approximate dimensions of the litter box(es) FORMTEXT ????? FORMTEXT ?????Type of litter used (ex: clay, clumping, wheat, etc.)? FORMTEXT ????? FORMTEXT ?????Is the litter scented or unscented? FORMTEXT ????? FORMTEXT ?????Brand of litter used? FORMTEXT ????? FORMTEXT ?????Have you tried other litter types/brands? If so, which types and brands?YES ? NO ? FORMTEXT ????? FORMTEXT ?????Do you use a litter box liner?YES ? NO ? FORMTEXT ?????Does your cat dig in the litter box before eliminating?YES ? NO ? FORMTEXT ?????Does your cat bury or attempt to bury urine/feces after using the litter box?YES ? NO ? SOMETIMES ? FORMTEXT ?????HOME ENVIRONMENT AND TRAININGBriefly describe home: House ? Townhouse ? Apartment/condo ? Number of floors: FORMTEXT ?????How long have you lived in this location? FORMTEXT ?????Please describe your neighborhood: Urban ? Suburban ? Rural ?Does your cat ever go outside? YES ? NO ? If so, when? FORMTEXT ?????Are there any stray or outdoor cats in your neighborhood? FORMTEXT ?????FOOD AND TOY MOTIVATIONItem Brand/typeHow often given?Motivation for this Cat food (canned) FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Cat food (dry) FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Table scraps/people food FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Treats (Pounce treats, etc.) FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Catnip FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Toys FORMTEXT ????? FORMTEXT ?????mild ? moderate ? strong ?Does your pet have any food allergies? FORMTEXT ????? If so, to what? FORMTEXT ?????Does your pet have a favorite toy or game? FORMTEXT ?????Is your cat trained to perform any commands? FORMTEXT ?????ACTIVITIES AND EXERCISE SituationAmount of time per day or week Location (bedroom, yard, etc.)In house, per day (if also outdoors) FORMTEXT ????? FORMTEXT ?????In yard, per day (if outdoors) FORMTEXT ????? FORMTEXT ?????Brushing FORMTEXT ????? FORMTEXT ?????Petting FORMTEXT ????? FORMTEXT ?????Playtime FORMTEXT ????? FORMTEXT ?????Sleeping during day FORMTEXT ????? FORMTEXT ?????Sleeping at night FORMTEXT ????? FORMTEXT ?????MEDICAL HISTORYIs your pet up to date on routine vaccinations, including rabies? YES ? NO ?MEDICATIONList any medication your cat currently receives. Please include any flea and heartworm prevention. Name of MedicationDose (mg) or amountHow often?Reason Given? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MEDICAL PROBLEMSPlease list any medical problems your pet has had.ProblemDates if known On going? FORMTEXT ????? FORMTEXT ?????YES ? NO ? FORMTEXT ????? FORMTEXT ?????YES ? NO ? FORMTEXT ????? FORMTEXT ?????YES ? NO ? FORMTEXT ????? FORMTEXT ?????YES ? NO ?Thank you for taking the time to fill out this form. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download