Feline Behavior Questionnaire

Pet Parent Information

First and last name:(Required)

Address:(Required)

Primary phone number:(Required)

Email:(Required)

List all veterinary clinics your pet has visited in the past 5 years:

Who referred you to the behavior service?

Please list the names of anyone we have permission to speak with regarding your pet, including any family members who will not be present at the initial consultation. We may only discuss your pet with their primary care veterinarian, others require written authorization.

Pet Information

Pet name:

Breed:

Color:

Date of birth/Age:

Sex:

Spayed/Neutered:

Yes

Age of spay/neuter:

Declawed?

Yes

Where and when did you get your cat?

Has your cat had other (human) parents prior to living with you?

Yes

Do you have information about your cat's history before you acquired them? If so, please explain.

What are your goals for this appointment?

List any existing health issues your pet has, including allergies or sensitivities:

What do you feed your pet?

What do you love the most about your cat?

Recent research has shown connections between gut health and brain health. Please mark how often your cat has any of the following signs:

Vomiting

Diarrhea

Constipation

Decreased appetite

Excessive licking

Lip licking

Environmental Information

How many adults are in the household?

Are there any children, elderly members, or immunocompromised individuals in the household or who visit regularly?

Yes

Check all that apply to your pet’s environment:

Indoor only

Indoor/outdoor

Outdoor only

Access to screened patio

Supervised outdoor time

How many play sessions does your cat get per day?

List any other pets in the household and their relationship with the patient:

Check all of the following that your cat has access to:

Designated scratchers

Climbing areas

Hiding areas away from people and other pet

Toys for play alone

Litter Boxes

Please complete the following regarding each litter box in your household.

Litter box 1:

Covered

Uncovered

Self-cleaning/electronic

Liner

What size is litter box 1?

What type of litter is in litter box 1?

Where is litter box 1 located?

Litter box 2:

Covered

Uncovered

Self-cleaning/electronic

Liner

What size is litter box 2?

What type of litter is in litter box 2?

Where is litter box 2 located?

Litter box 3:

Covered

Uncovered

Self-cleaning/electronic

Liner

What size is litter box 3?

What type of litter is in litter box 3?

Where is litter box 3 located?

Litter box 4:

Covered

Uncovered

Self-cleaning/electronic

Liner

What size is litter box 4?

What type of litter is in litter box 4?

Where is litter box 4 located?

Litter box 5:

Covered

Uncovered

Self-cleaning/electronic

Liner

What size is litter box 5?

What type of litter is in litter box 5?

Where is litter box 5 located?

How often are the litter boxes scooped?

How often are the litter boxes completely emptied and washed?

Presenting Concerns

List the first concern for which you are seeking help:

Age problem 1 started?

Unknown

Less than 4 months old

4 to 12 months old

1 to 3 years old

3 to 7 years old

7 years old or later

Frequency of problem 1?

Always

Sometimes

Rarely

Never

Has problem 1 gotten:

Better

Worse

Unchanged

Describe the most recent 2 incidents of this problem:

List the second concern for which you are seeking help:

Age problem 2 started?

Unknown

Less than 4 months old

4 to 12 months old

1 to 3 years old

3 to 7 years old

7 years old or later

Frequency of problem 2?

Always

Sometimes

Rarely

Never

Has problem 2 gotten:

Better

Worse

Unchanged

Describe the most recent 2 incidents of this problem:

List the third concern for which you are seeking help:

Age problem 3 started?

Unknown

Less than 4 months old

4 to 12 months old

1 to 3 years old

3 to 7 years old

7 years old or later

Frequency of problem 3?

Always

Sometimes

Rarely

Never

Has problem 3 gotten:

Better

Worse

Unchanged

Describe the most recent 2 incidents of this problem:

Previous Treatments

Check all previous treatments that have been tried:

Other treatment:

Sleep Behaviors

Does your pet sleep through the night?

Yes

Have there been any changes in your pet’s sleeping patterns in the past 3 months?

Yes

Does your pet take naps during the day?

Yes

Elimination Behaviors

If your cat eliminates or defecates outside of the box, please fill out the following questions. If not, move on to Fearful Behaviors.

What does your cat do outside of the box?

Urinate

Defecate

Both

How often does your cat eliminate outside of the box?

Always

Daily

Several times per week

Weekly

Monthly

Every few months

Check all that apply to your cat’s behavior when using the litter box:

When your cat eliminates outside of the box, check all that apply:

Stands and sprays urine

Urinates on horizontal surface

Urinates on vertical surface

Urinates a small amount

Urinates normal/large amount

Scratches as if to cover

Eliminates on hard surfaces

Eliminates on soft surfaces

Eliminates in a specific spot

What do you use to clean soiled areas? List all that you have tried.

Fearful Behaviors

Check all that apply to your cat’s behavior when you have visitors:

Check all that apply to your cat’s behavior when another cat in the home is nearby:

Check all that apply to your cat’s behavior when there is a new item in the home:

Check all that apply to your cat’s behavior when an unfamiliar animal is nearby:

Aggressive Behaviors

Aggression describes a behavior, but it is not a personality trait. Aggressive behaviors include growling, hissing, swatting, scratching, and biting. If your cat has exhibited these behaviors in some situations, please answer the following section. If not, continue to the next section. These answers help your pet’s doctor appropriately diagnose and determine the best treatment plan for your cat.

Has your pet ever bitten at a person (this includes an air snap)?

Yes

Number of bites to a person:

Number of bites that broke skin:

Has your pet ever bitten at another cat (this includes an air snap)?

Yes

Number of bites to a dog:

Number of bites that broke skin:

Has a bite ever been reported to public health authorities?

Yes

Has there been any legal action regarding your cat's behavior?

Yes

When is your cat aggressive?

What other time is your cat aggressive?

Who is your cat aggressive toward:

Check all that apply to your cat’s body language when they are aggressive:

Describe other body language when aggressive:

Separation Behaviors

If your pet exhibits distress when separated from you or left alone, please fill out the following section. If not, move on to Storms/Sound Behaviors.

Behavior when you get ready to leave (check all that apply):

Aggressive toward you

Avoids being confined

Attempts to escape

Calm

Hides

Looks sad

Follows you around

Cries

Other

Other behavior when you get ready to leave:

Behavior while you are gone or cannot be reached (check all that apply):

Other behavior when you are gone or cannot be reached:

Does your cat exhibit this/these behavior(s) every time they are alone?

Yes

Does your cat exhibit this/these behavior(s) when a certain person departs, but not others?

Yes

Describe anything else you would like to share about your pet’s behavior when you leave:

Storms/Sound Behaviors

If your pet exhibits fear or stress related to storms or noises, please fill out the following section. If not, move on to Veterinary Visits.

What sounds cause your cat to exhibit fear or stress (check all that apply):

Other sounds that cause your cat to exhibit fear or stress?

What is your cat's body language in response to a scary sound (check all that apply):

Other body language in response to a scary sound?

How long does it take your cat to calm down after sound/storm ends?

Veterinary Visit Behavior

Check all that apply to your cat in the veterinary office and during examination:

Does your cat excessively groom themselves?

Yes

Have euthanasia or rehoming been recommended or considered prior to your visit with us?

Yes

Medical Records

Please have your veterinarian and any specialists your pet has seen send us your pet’s medical records, including any lab work. Documents can be uploaded below or sent by email to petshrink@pazvet.com or by fax to 512-481-7071

The Day Of:

Please schedule a consult for all pets that are involved in the problem if you can do so safely. If multiple pets are involved and only one pet can come to the appointment, then the doctor may recommend a consult for your other pet(s) to adequately treat the problem. Please bring your pet's favorite toys and treats with you to the appointment so that we can use those items during your pet's appointment, if appropriate.

Photos and Videos

Videos of problem behaviors may be helpful. Do not under any circumstance invite or trigger aggressive behavior for the purpose of a video. Please limit videos to 2 minutes or less so they can be quickly added to your pet’s medical record.

File Uploads

Drop files here or

Max. file size: 50 MB.

Please be patient and allow all files to upload prior to continuing.

If you provide a video or pictures of your pet(s), would you give us permission to use them for teaching purposes in textbooks, publications such as journals, and during teaching presentations?

Yes

Each pet is an individual, so results of behavioral therapy cannot be guaranteed. While improvement can be seen quickly, many emotional disorders are chronic in nature and require continued therapy. Response to therapy is dependent on the individual’s response and the implementation of the recommendations made by your pet’s doctor. The behavior service is unable to guarantee that a treatment plan will be able to completely remove a patient’s aggression or potential danger to people or other animals. Pets should always be managed in accordance with local ordinances and leash laws.

By signing below, I acknowledge that:

I am the legal owner of the pet seeking behavioral medicine treatment from the behavior service at PAZ Veterinary.

Follow up appointments for behavior therapies range from every 4 to 6 weeks to every few months depending on the case.

Fees are to be paid at time of service and I accept responsibility for all charges that I approve related to the treatment of my pet.

I am seeking treatment by the behavior service with full knowledge of the above and of the liability associated with ownership of a pet that has exhibited aggression in the past.

Signature