Preferred Pronouns Primary Phone * Primary Email * Do you wish to be contacted by phone or email? Name of Pet Breed Date of Birth/Age Sex Who is your regular veterinarian? Clinic Name Did someone other than your vet refer you? If yes, who? We may offer treats during the consultation. Please let us know if that is OK and if so, does your cat have any food allergies or sensitivities? Do you have any food allergies (ex. shellfish) Please provide the names of additional family and pets members and their ages in the household (age, sex, breed), as well as the order of acquisition for the pets. * What is the primary behavior problem or complaint? * Additional problems (please list): How frequently do the problem(s) occur? (How many times daily, weekly or monthly) When did the problems first start to occur? * What have you done so far to try and correct the problem(s)? * What are some good qualities about your cat? * How long have you had your cat? How old was your cat when you first acquired him/her? Where did you get your cat? Has this cat had other owners? If yes, how many? Why was the cat given up by the previous owners? Have you owned cats before? How would you describe your cat's overall personality now? Does your cat use a litter pan? Does your cat ever eliminate in the house (outside the litter pan)? How many litter pans do you have? Where are they (please be specific: which room, which floor)? What types of pans (indicate number)? Open top commercial litter pan Covered box (“cave”-type front door) Covered box (“Booda”-type front door, cat crawls into hole on top) Automatic litter box (LitterMaid, CatGenie) Other (please describe) How old is each pan? Do you use a liner? If yes, what type (plastic, newspaper, etc.)? What type of litter is used (please be specific): How often is litter scooped, and how often do you wash the box(es)? Does the cat cover urine/feces in the box? Will the cat immediately use a freshly cleaned litter box? Does the cat ever vocalize while it eliminates? Does the cat ever run out of the box after eliminating? What do you feed your cat? (Please be specific about brand name, amount of food and when given) Has your cat's appetite (increased, decreased, no change)? What is your cat's favorite treat? What is your cat's relationship to the other animals (e.g. friendly, hostile, fearful)? Please describe: What type of area do you live in? (City/ Suburb/ Rural) Have you moved since acquiring your cat? If yes, how many times? Has your household (people or animals) changed since acquiring your cat? If yes, please describe: Does your cat go outdoors? How does your cat behave with adult visitors/children? How does your cat behave at the veterinary hospital? How does your cat respond to cats seen out of the window or in the yard? Does your cat vocalize? When? Please be specific (e.g. Meow, hiss, growl) How do you play with your cat? What types of toys are used by your cat? What is your cat's general activity level? Is your cat up-to-date on vaccinations? * Please give a brief medical history, including any recurring problems/treatments. * Has your cat recently had blood or urine testing? * Is your cat currently on any prescribed medications or supplements? If so, for what conditions? * Has your cat ever taken any medications, supplements, or have you used any pheromone products for behavioral problems? If yes, please list drug and dosage when taken. * What are your goals for you and your cat with working with a veterinary behavior clinic? * Any Additional Comments: Please send photos and videos of your home layout, including the locations of the litter boxes, resting places for your cat, and any other important information to our email: email@example.com, or please bring them to your initial consultation appointment.
Please note: Your behavior history form was uploaded to the Veterinary Behavior of Indiana's email address once you get a confirmation page with a picture of a large dog.