Please complete prior to the behavior consultation and bring it with you to the appointment.

1. Pet’s Name_______________

Your Name_______________

2. Breed_________ Color___________

3. Date of Birth/Age___________

4. Sex ____Male ______Female

5. Spayed/Neutered? Yes/No

If yes, at what age?__________

Any behavioral changes after neutering? _________

6. If not neutered, do you plan to breed this cat?

Yes/No

7. If the cat is a female, has she ever had a litter?

Yes/No

8. Declawed? Yes/No

If yes, at what age? _______

If yes, reason for declawing? __________________

9. How old was this cat when he/she was acquired? ______

10. Where did you get this cat?

Stray ____ Breeder ____

Shelter/Humane Society _____ Friend _____

Pet Store ____ Other (please explain) ______

11. Has this cat had previous owners since a kitten?

Yes/No

If yes, how many?__________

Why was the cat given up? ___________________

12. Why did you get this cat?____________________

Have you had cats before?___________________

13. Is this cat - check all that apply

- Indoors only ____

- allowed outside unsupervised ____

- outside unleashed but supervised ____

- leash walked ____

14. % of time: Indoors ____ Outdoors ____

15. What is your living situation?

Apartment/Condo ____ What floor? ____

Townhouse ____

Single Family home ____

16. What does this cat eat? _____________________

Frequency - food always available ____

Number of times fed per day ______

17. How often are treats given? __________________

18. How often is it fed snacks from the table (i.e. human food)? ____________________________

19. How would you describe its eating habits (e.g. picky, voracious)?_________________________

Has this changed recently?__________________

20. Does this cat have any allergies? Yes/No

Please specify____________________________

21. Does he/she have any medical problems? Yes/No

Please specify ____________________________

22. Is he/she taking any medications(e.g. heartworm or flea preventatives)? Yes/No

Please specify ____________________________

23. Has your household changed since acquiring this cat? Yes/No If so, how?

Death of a human in the family ____

Death of a pet in the family ____

Marriage ____ Divorce _____

Baby born ____ Child moved ____

Pet added ____

Family moved ____

Families’ schedule changed ____

Other __________________________________

24. Please list the people, including yourself, currently living in the house hold. Please include name, sex, age(if a child), relationship(self, spouse, child, roommate, etc), and occupation for each.

25. Please list other pets in the household. Please include name, species, breed, sex, age obtained, age now, and label using numbers the order in which they were obtained.

26. Describe where the cat stays/sleeps at each of the following times:

Daytime when the owners are home___________

Daytime when the owners are away ___________ Nighttime_______________________________

When guests visit _________________________

27. Does he/she wake you up for food or attention during the night? Yes/No

If yes, at what time and what do you do?

28. Is your cat interested in playing? Yes/No

If yes, when is he/she most interested? _________

Favorite toys? ____________________________

How often and for how long do you play with him/her? ________________________________

29. How long is he/she left alone on the average day?

30. How does your cat react to the following situations? Car rides ________________________________

Loud noises ______________________________

Strangers ________________________________

New (non-family) cats or dogs _______________

31. What is (are) the behavioral problem(s) that you wish to address, and how much of a problem do you consider the behavior to be? Please list and rate not serious, serious, very serious and how long each has been a problem.

32. If this is an ongoing problem, what have you tried in the past and was it effective?( If the behavior is inappropriate urination, answer this on the next form)

33. If this is an ongoing problem, why have you kept the cat?

34. Are you concerned you may have caused the problem? Yes/No

Why?___________________________________

35. Do you feel guilty? Yes/No

Why?___________________________________

36. Have you considered finding another home for the cat? Yes/No

37. Have you considered euthanasia? Yes/No

38.Is there anything else you would like to tell us about your cat’s behavior?