Step 1 of 6 16% Client InformationPlease complete this form and we will call you to schedule an appointment. Please videotape your pet performing the behavior(s) before your visit, if possible. Thank you and we look forward to working with you and your pet(s)!Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Home)WorkAlternateEmail* Other Contact InformationCat InformationName*Breed*Age*Sex*SexMaleFemaleWeight*Neutered/Spayed* Yes No At what age?Declawed?* Yes No At what age?Referring Veterinarian InformationDoctor Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxEmail Chief Complaint1. What is the main behavior problem or chief complaint?*2. When did the problem begin?*3. When does your cat misbehave? How often and under what circumstances?*4. Has there been a change in frequency or appearance of the problem?*5. What has been done so far to correct the problem?*6. Describe the first incident.*7. Describe the most recent incident.*8. Describe the next most recent incident.*9. Other incidents?*10. Are there any other behavior problems?* Cat's Environment11. List all members of your household and their schedules:*Name, Age, Hours away from home, Time spent with cat12. List all pets in household in the order in which they were obtained:*Name, Breed, Sex, Age, Interaction with catIf you have a multiple cat household, do you ever notice starting, growling, hissing, chasing, or fighting between any of your cats?13. Where is your cat kept during the day? At night? When owner is away (i.e. on vacation)?*14. How is the cat exercised? Does he/she run free? How and when do you play with your cat? Does your cat play with other pets?*15. Describe a typical day in the cat's life.*Early History16. Why was your cat obtained?*17. Source of the cat?*18. Age at weaning?*19. Age when obtained by present owner?*Feeding20. What is your cat fed and when is he/she fed?*21. Who feeds the cat? Can you take the food away from your cat?*22. Does your cat have a good appetite? Does he/she like treats?*Grooming23. Does your cat keep his/her coat in good condition? Are there any areas which are licked excessively?*24. Does your cat tolerate being brushed or enjoy it?* Social25. Is your cat aggresive or timid with other cats? With other species?*26. How does your cat act with:Friends*Children*Strangers*Veterinarians*Other Information27. Does your cat sleep through the night? Is he/she restless at night? Where does he/she sleep at night?*28. Does your cat vocalize excessively? If yes, when?*29. How does your cat react to loud noises or storms?*30. How does your cat react when he/she is left alone?*31. Has your cat been bred or used for breeding? If yes, was she a good mother?*32. Does your cat every “mother” toys or other animals?* Medical History33. Brief medical history:*34. Does your cat have any history of urinary or gastrointestinal tract problems, including a urinary tract infection or obstruction, constipation, or diarrhea?*Behavior at the litter boxNumber of available boxes in your house?Litter Box #1Litter (brand)?Depth of litter?Times/day it is scooped?How is the box cleaned?Liners?Where is it located?How far from food/water?How far from noisy sources (i.e. vents)?Covered?How old is the box?Size of box?How often do you empty the entire contents of the box?Litter Box #2Litter (brand)?Depth of litter?Times/day it is scooped?How is the box cleaned?Liners?Where is it located?How far from food/water?How far from noisy sources (i.e. vents)?Covered?How old is the box?Size of box?How often do you empty the entire contents of the box? 35. Does your cat use the litter box regularly? For both urination and defecation?*36. Does your cat urinate outside the box? If so, please list ALL locations.*37. Does your cat defecate outside the box? If so, please list ALL locations.*38. Are there certain objects or materials outside of the box on which your cat will eliminate? If so, what?*39. Does your cat’s urine or stools ever appear abnormal, either inside or outside of the box?*40. Before eliminating in the litter box: does your cat sniff, dig, and turns?*41. After eliminating: does your cat cover the wastes? Does your cat shake his/her paws?*42. Does your cat prefer using the litter box once scooped?*43. If your cat is NOT using the litter box, describe your house plan (or bring a sketch at the Initial Consultation). Please, indicate: where your cat is eliminating, where the litter boxes are, where the food/water bowls are, and where the resting locat*44. How are the soiled spots cleaned? What detergents are used?*45. Did you ever catch your cat in the act?*46. Could you describe his/her body posture?*47. Is your cat eliminating small or big amounts of urine?*
