PETFAX Feline Behavior Fax Sheet

Instructions:
The owner(s) should fill out the following form thoroughly yet concisely. PLEASE ANSWER EACH QUESTION DIRECTLY ON THIS FORM IN THE SPACE PROVIDED. LIMIT ADDITIONAL INFORMATION TO ONE TYPEWRITTEN PAGE IF NECESSARY. Print out and fax both the completed Behavior Fax Sheet and the Initial Consultation Request Form to 1-508-839-8734. If you have questions, call 1-508-887-4640.

Date: Recorder:
Name & Address of owner:
Email Address:
Telephone: Fax:
Name of cat: Breed:
Age of cat now: Age at which cat was acquired:
Weight:                Color: Sex:
Neutered: Age of neutering:
Reason for neutering:
Any behavioral changes following neutering?
Has the cat been declawed? At what age?
Date of last physical examination:
(Please include copies of any relevant medical records and/or blood work.)
Any medical problems?
Any current medications (please include dose if known)?
WHAT IS YOUR CAT'S BEHAVIOR PROBLEM?
Age of onset:
Duration of each incident:
Frequency of occurrence:
Have there been any changes in the pattern, frequency, intensity and/or length of incidents from the time of onset to the present?
Are there any specific conditions which seem to trigger the behavior?
Can the cat be interrupted when engaged in the behavior?
How long is the interval between the behavior stopping and the beginning of the next occurrence?
Describe any methods used to stop the behavior and the cat's response to these methods:
Please give a detailed description of the last time this problem occurred:
CAT'S HISTORY
Where did you get the cat from:
Do you know if the cat's parents or siblings engaged in similar behaviors or any other abnormal behaviors?
How would you describe your cat's temperament (check where appropriate)?

____ calm     ____ hyperactive    ____ timid     ____ anxious/nervous
____ shy    ____ aloof    ____ affectionate

____ other (describe): ________________________________________________

List people living in the house with the pet, include children's ages:
Has the cat ever changed owners?
Has the cat ever moved house?
List other animals in the household, their species, breed, age, sex and whether or not they are neutered. Please note which of these animals were living in the house when this cat was acquired:
Describe interactions between pets in the household:
Do the animals eat together?
Describe interactions between cat and family members:
Has any human or pet to whom the cat was bonded left the home?

Did this coincide with the onset of any of the problem behavior(s)?

Did any of the problem behavior(s) coincide with the addition of a new animal or human to the household?

Is the cat primarily an indoor or outdoor pet?

Was the cat previously allowed to go outside but is now restricted to being indoors (or vice versa)?

How does the cat react to other cats outside the house?

1. When the cat is indoors and sees other cats through the window:



2. When the cat is also outside:

Behavior of cat with strangers in the home:

Behavior of cat in veterinary office and during examination:

DAILY ACTIVITIES
Please describe a typical 24 hour period in your cat's life, start with where and when the cat wakes up in the morning:
DIET
Type of food:
Frequency of feeding:
Amount fed:
Does the cat hunt?
If yes, does the cat eat the animals it catches?
LITTERBOXES
Number of litterboxes in the house:
Location of litterboxes:

Type of litterbox (open/closed; large/small):

Type of litter used:

Have you used different types of litter in the past?

If so, did changing type affect the cat's behavior?

If the cat's behavioral problem, involves inappropriate urination/defecation, is there one particular location or on a particular type of surface/material other than its litterbox which the cat tries to use?:

 

How often does your cat urinate in the litter box as he/she should?
(check where appropriate)

____ 100% of the time    ____ 75% of the time   ____ 25% of the time   ____ Never

How often does your cat defecate in the litterbox as he/she should?
(check where appropriate)

____ 100% of the time    ____ 75% of the time   ____ 25% of the time   ____ Never

Have you ever noticed your cat straining to urinate or defecate?
Have you ever noticed any blood in your cat's litterbox?
Frequency of cleaning of litterbox:
Please provide the following information about your cat ’s local veterinarian:
Name:
Business Address:
Phone Number:
How did you hear about Tufts Animal Behavior Clinic?:

Thank you for using PetFax.

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