Cat Behavior Intake Form

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Owner Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Pet's Name(Required)

Breed(Required)

Sex(Required)

Age(Required)

Color(Required)

Who is your cat's primary veterinarian?(Required)

Please list all veterinary hospitals where your cat has been seen in the past 5 years.

BEHAVIOR VIDEO —

Please take a 2 minute or less video of the behavior(s) when you think it will be helpful. Once you have your video, please send the video via text message to (631) 923-2530. Please include your name and your cat’s name on the video submission.

IMAGE AND VIDEO CONSENT —

We may take pictures and videos as a part of your pet’s appointment. Below is a consent questionnaire for our use of images of your pet. When used, there will be no identifying information of your pet or you, such as your name. Please consent below to whichever options works best for you.

Image and Video Consent Choice(Required)

My pet’s pictures and videos can be used for my pet’s medical record, textbooks, and veterinary publications, including journals, electronic publications, and veterinary presentations.

My pet’s pictures and videos are to be used for my pet’s medical record only.

Do not use my pet’s picture for any purpose, including in his or her medical record.

CAT BEHAVIORAL QUESTIONNAIRE —

PLEASE MARK ALL OF THE APPROPRIATE BOXES AND FILL IN THE BLANKS TO THE BEST OF YOUR ABILITY

How long have you had your cat?(Required)

Where did you get your cat?(Required)

Has your cat had any other owners?(Required)

Yes

How many previous owners has your cat had?(Required)

If you know, please explain why your cat was relinquished by the previous owner(Required)

How many people are in your household?(Required)

Has there been any significant change in your household's routine or schedule in the past 3 months?(Required)

What are your goals for this appointment?(Required)

If you feel that the relationship of the cat with a particular person is important to the assessment and treatment of the problem for which you are bringing your cat, please describe.

Tell us about your pet's environment. Check all that apply.(Required)

Indoors only

Outdoors only

Indoor, access to the screened-porch/lanai when let out

Indoor, access via cat door to screened-porch/lanai when let out

Indoor / Outdoor

Indoor, walked on leash

Indoor, outside with supervision

Do you have multiple pets?(Required)

Yes

List what pets you have in the home and their ages(Required)

Does your cat…?(Required)

Sleep with your other cat(s)

Sleep with your dog(s)

Groom your other cat(s)

Groom your dog(s)

Play with your other cat(s)

Play with your dog(s)

HEALTH, WELLNESS, AND WELFARE

What is your cat's activity level in general?(Required)

Low

Average

High

Excessive

Does your cat take naps during the day when you are home?(Required)

Yes

Does your cat sleep through the night?(Required)

Yes

Have you noticed any change in your cat's sleeping patterns in the past 3 months?(Required)

Yes

Does your cat experience any of the following?(Required)

Vomiting

Diarrhea

Constipation

Decreased appetite

When does your cat experience vomiting?(Required)

Daily

Weekly

Monthly

Several times per year

When does your cat experience diarrhea?(Required)

Daily

Weekly

Monthly

Several times per year

When does your cat experience constipation?(Required)

Daily

Weekly

Monthly

Several times per year

When does your cat experience decreased appetite?(Required)

Daily

Weekly

Monthly

Several times per year

Please describe any significant medical illnesses, treatments, and the outcomes.(Required)

How many play sessions does you cat get per day?(Required)

What do you feed your cat?(Required)

Does your pet have any allergies or food sensitives? If yes, please describe.(Required)

BEHAVIOR PROBLEM INFORMATION

Please fill out the section below regarding your three top concerns about your pet’s behavior.

Please describe problem #1(Required)

At what age did problem #1 start?(Required)

Less than 4 months old

4 months – 1 year

1 – 3 years

3 to 6 years

6 – 10 years

More than 10 years

Frequency of problem #1(Required)

More than 1 time per day

1 time per day

3 – 6 times per week

1 – 3 times per week

Less than 1 time per week

Please give a description of the significant representative event for problem #1.(Required)

Please describe problem #2

At what age did problem #2 start?

Less than 4 months old

4 months – 1 year

1 – 3 years

3 to 6 years

6 – 10 years

More than 10 years

Frequency of problem #2

More than 1 time per day

1 time per day

3 – 6 times per week

1 – 3 times per week

Less than 1 time per week

Please give a description of the significant representative event for problem #2.

Please describe problem #3

At what age did problem #3 start?

Less than 4 months old

4 months – 1 year

1 – 3 years

3 to 6 years

6 – 10 years

More than 10 years

Frequency of problem #3

More than 1 time per day

1 time per day

3 – 6 times per week

1 – 3 times per week

Less than 1 time per week

Please give a description of the significant representative event for problem #3

If multiple problems are described, please rank the problems above in order of importance from most important to least important.

ELIMINATION BEHAVIORS

Does your cat ever eliminate outside the litter box, in the house?(Required)

Yes

Does your cat urinate outside of the litter box?(Required)

Yes

Does your cat defecate outside of the litter box?(Required)

Yes

When your cat uses the litter box, does he or she…? Check all that apply.(Required)

Scratch before eliminating

Cover feces

Cover urine

Immediately use a clean box

Cry or meow

Run out of the box when finished

Scratch outside of box

When your cat urinates or defecates outside of the litter box, does he or she…? Check all that apply.(Required)

Scratch as if to cover

Stand and spray urine

Urinate on horizontal surfaces

Urinate on vertical surfaces

Urinate on hard surfaces

Urinate on soft surfaces

Urinate in a particular place

What are you using to clean the soiled areas? Check all that apply.(Required)

Vinegar and Water

Nature’s Miracle

Urine Off

Zero Odor

Dish Soap

Febreeze Pet Odor

Carpet Cleaner

Anti Icky Poo

Other

Define "other"(Required)

LITTER BOX INFORMATION

Describe the location of litter box #1(Required)

Is litter box #1 covered or uncovered?(Required)

Covered

Uncovered

Does litter box #1 have a liner?(Required)

Liner

No liner

What type of litter is used in litter box #1?(Required)

Describe the location of litter box #2

Is litter box #2 covered or uncovered?

Covered

Uncovered

Does litter box #2 have a liner?

Liner

No liner

What type of litter is used in litter box #2?

Describe the location of litter box #3

Is litter box #3 covered or uncovered?

Covered

Uncovered

Does litter box #3 have a liner?

Liner

No liner

What type of litter is used in litter box #3?

How often are the litter boxes scooped?(Required)

Daily

As the cat uses it

Multiple times per day

Every other day

Weekly

How often are the litter boxes emptied, washed and the litter replaced?(Required)

What previous treatments have been tried? Check all that apply.

AGGRESSIVE BEHAVIOR

Does your cat exhibit aggressive behaviors (biting, scratching)?(Required)

Yes

Has your cat ever bitten a person or other animal?(Required)

Yes

Your pet exhibits aggressive behavior towards…? Check all that apply.(Required)

Family members in the home

Other cat(s) in the home

Dog(s) in the home

Visitor(s) to the home

Cat(s) outside the home

Veterinary team

Other

Describe "other"(Required)

When is your cat aggressive? Check all that apply(Required)

Describe "other"(Required)

What does your cat do when separated from the family? Check all that apply.(Required)

Cries, meows, howls

Urinates outside of the litter box

Defecates outside of the litter box

Hides

Puffs up

Destroys

Other

Describe "other"(Required)

What does your cat do when visitors enter the home? Check all that apply.(Required)

Cries, meows, howls

Urinates outside of the litter box

Defecates outside of the litter box

Hides

Puffs up

Destroys

Hisses

Escapes

Other

Describe "other"(Required)

What does your cat do when another household cat approaches? Check all that apply.(Required)

Describe "other"(Required)

What does your cat do when a new object is in the home? Check all that apply.(Required)

Describe "other"(Required)

What does your cat do when an unfamiliar animal approaches? Check all that apply.(Required)

Describe "other"(Required)

What does your cat do when he or she hears a loud noise? Check all that apply.(Required)

Describe "other"(Required)

EUTHANASIA / REHOMING

Did someone recommend euthanasia before your visit to us?(Required)

Yes

Have you considered euthanasia before this visit?(Required)

Yes

Have you considered re-homing you cat before your visit?(Required)

Yes

Anything else you'd like to share with us about your cat?

AUTHORIZATION

I am the owner of the animal seeking behavioral medicine treatment from Gold Coast Center for Veterinary Care. Behavioral treatment, training, and advice, when properly maintained after completion, can be very helpful in resolving problem behaviors in animals. Because each pet is an individual, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior, including aggression, is unpredictable and will remain unpredictable after its treatment. Gold Coast Center for Veterinary Care cannot promise that the animal’s behavior service treatment, training or advice will completely eliminate the animals potential danger to persons or completely control the animal’s aggressiveness.

I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.

I understand that all fees are to be paid at the time of service and accept full responsibility for the charges incurred in the treatment of my pet.

Telehealth appointments may be recorded for internal training only.

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