Home Phone:
Cell Phone:
Employer's Name:
Work Phone:
Email: *
Name of preferred local pharmacy:
Phone:
Fax:
Feline's name: *
Age:
Breed:
Color:
Age when performed:
Weight:
Date and age when acquired (if known):
If Other, please explain:
Reason for obtaining this cat:
Litter size (if known):
Age when weaned (if known):
Describe your cat's personality:
If so, at what age?
How much interaction did the kitten have with people in the first year of life?
What method of litter training was used?
Your reaction to mistakes during litter training:
Was there any interaction with other cats during the first year? If so, provide details:
Primary veterinarian:
Clinic name:
Phone:
Fax:
Please list the most recent set of vaccinations received and the date(s):
Referred by:
Provide medical history (infection/surgeries) and prescribed treatment:
Please explain change in eating habits:
Please explain change in drinking habits:
If so, describe the treatment and medication (if applicable):
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name, Type and Breed:
Age:
Relationship with cat (fight, play, avoid)
Name, Type and Breed:
Age:
Relationship with cat (fight, play, avoid)
Name, Type and Breed:
Age:
Relationship with cat (fight, play, avoid)
Name, Type and Breed:
Age:
Relationship with cat (fight, play, avoid)
Brand(s) (e.g., Purina, Eukanuba, Friskies):
Who is primarily responsible for the feeding?
Quantity of food given:
At what approximate time(s) of day is food given?
Where is the cat fed (physical location)?
Where is the cat fed in relation to other cats in the household?
What are your cat's favorite foods?
How much water does your cat drink in a day?
How many water bowls are provided?
How much milk does your cat drink in a day?
If so, provide details:
Where does your cat sleep at night?
Where does your cat sleep during the day?
When does your cat get up in the morning?
If yes, how often and have you any idea why?
Where can your cat normally be found during the day?
If so, how long does it like to stay out for in the summer?
If so, how long does it like to stay out for in the winter?
What area is available for the cat to roam outside?
Have there been any changes in your household routine (e.g., new baby, change in working hours, moving, new roommate, visitors, dietary changes) or living arrangements?
How many litter boxes are provided?
If yes, how recently? From how many to how many?
If yes, how recently? From where to where?
Describe the shape and size of each box:
What type and brand of litter is used?
If yes, how recently? From what, to what?
How often is the waste material scooped out?
How often is the litter box completely cleaned out and washed?
If yes, how recently? From what, to what?
What do you use to clean and wash the actual box?
How many times per day does it use the box?
How long has this behavior been going on?
What time of day do you usually find the deposits outside of the litter box (e.g., morning, afternoon, after work, overnight)?
Where is the cat eliminating outside the box? Please list room, locations, number of deposits:
If yes, please explain:
If yes, what was your response and what was the cat's response?
When was the last time a urine sample was examined by your veterinarian?
What approaches (medical, environmental, or behavioral) have been used in the past to attempt to address the problem?
If yes, please specify:
Housemates Names:
Describe your cat's appearance when defending its territory:
Names:
Names:
Names:
What type of prey does it catch?
If yes, provide details:
If other, provide details:
Does your cat come when called or do any tricks?
How does your cat respond to catnip?
If other, provide details:
What arrangements are made for the cat if you are away from home for some time (e.g., on vacation)?
Typically, how long is your cat left alone without human company on any given day?
At what age was your cat declawed?
Describe the type and location of the post(s):
Please describe:
If other, provide details:
To which areas of your home does your cat have access?
Please describe your cat's reaction, aggression exhibited, and to whom during brushing/grooming:
Please describe your cat's reaction, aggression exhibited, and to whom during petting, hugging, or holding:
Please describe your cat's reaction, aggression exhibited, and to whom when disturbed during resting:
Please describe your cat's reaction, aggression exhibited, and to whom during disciplining:
Please describe your cat's reaction, aggression exhibited, and to whom when playing:
Please describe your cat's reaction, aggression exhibited, and to whom when giving treats:
Please describe your cat's reaction, aggression exhibited, and to whom when putting the cat in the carrier:
How does your cat behave when visitors come to the house (e.g., hides, shows interest in visitors, interacts with them)?
If yes, provide details:
If yes, and this is not the primary complaint at the present time, please provide brief details:
If yes, please provide the information (Name(s), purpose(s), time and days, cat's reaction(s))
What is your cat's response to frequent visitors?
What is your cat's response to occasional visitors?
What is your cat's response to rare visitors?
Details:
Details:
Details:
Details:
Details:
Details:
Details:
Details:
Details:
Details:
When does your cat meow?
When does your cat growl?
When does your cat purr?
If yes, please describe this behavior:
Details:
If yes, give details:
How do you correct your cat when it misbehaves?
If yes, describe these:
Describe the problem you are currently experiencing with your cat:
When did this problem begin?
Did it coincide with any event or action that you can identify?
How old was the cat when the problem began?
Where does the problem commonly occur?
With whom does it occur?
How often does it occur?
What approaches have been tried to correct the problem?
Do you suspect any cause?
Describe the three most recent episodes of the behavior:
If yes, please explain in detail:
Describe the most recent incident and the setting in which is occurred (be precise):
Where was the cat?
Where was everyone else in relation to the cat?
What was everyone doing prior to the incident?
What was the cat's body posture (position of ears, tail, face, fur)?
What was your reaction or response?
What was the cat's reaction to your response?
If so, give details:
Describe the previous three incidents prior to the most recent incident:
If other, please explain:
What has been done to correct the problem?
Do you suspect any cause?
How would you describe your own and your family's relationship with this cat? (Adult owners & children)
What are your own and your family's feelings about the cat's present behavior? (Adult owners & children)
What is your expectation for change?
Under what circumstances would you consider rehoming this cat?
Under what circumstances would you consider relinquishing this cat to a shelter or rescue?
Under what circumstances would you consider euthanasia?
Describe the scenarios seen in videos:
