Today's Date * 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? What is the main behavior problem or complaint? Additional problems (please list): Please list all problems. How frequently do the problem(s) occur? (how many times daily, weekly or monthly) 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? Why did you acquire this cat? Have you owned cats before? Did you meet this cat’s parents or littermates? Do you know if the parents or littermates engaged in similar behaviors? Chronology of the Behavior Problem When did you first notice the main problem (age of cat)? When did it first become a serious concern? Describe the chronology of the behavior problem, i.e. how it developed over time: Describe several examples in detail: When, where and what other animals or people were present. What have you done so far to try to correct the problem? 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? Will the cat eliminate in the presence of other animals or people? 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, e.g. brand name) Has your cat's appetite (increased, decreased, no change)? How much do you feed? (please be specific) How often? What is your cat's favorite treat? Please list the people, including yourself, living in your household: Please list all animals in the household: Name, Species, Breed, Sex, Age Obtained, Age Now In what sequence were the above animals obtained? 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 do you play with your cat? 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? When does your cat meow? When does your cat hiss or growl? What types of toys are used by your cat? What is your cat's general activity level? How would you describe your cat's personality? 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 medication for behavioral problems? If yes, please list drug and dosage and when taken. What are your goals and expectations regarding the appointment? Any Additional Comments: If you think a floor plan or drawing of your house would be helpful, please feel free to include one.