NC STATE UNIVERSITY

Behavioral Medicine Service

NCSU Veterinary Health and Wellness Center

1060 William Moore Drive ∙ Raleigh, NC 27607

Phone: 919-513-6999 ∙ Fax: 919-513-6905

www.animalbehaviorservice.com ∙

FELINE BEHAVIORAL HISTORY FORM

The information you provide here is very important in the diagnosis and treatment of your cat’s behavior problem. Please fill out this form as completely and accurately as possible.

§  Mail, fax, or e-mail this form to the NCSU Behavioral Medicine Service before your appointment.

·  Please, bring a map of your home and yard to your appointment. Use keys to indicate the location of each of the following: F = Feeding location, P = Play area, SD = Sleeping (day), SN = Sleeping (night), U = Urine house-soiling, BM = Fecal house-soiling. Use 1, 2, 3, etc. to indicate litter box(es) and respective location(s).

§  If possible, bring a video recording of your pet exhibiting its behavior problem.

Today’s Date:

PART I. INFORMATION

OWNER INFORMATION

Last Name: First Name: Spouse/Partner:

Street Address: City: State: Zip:

Primary Phone: Home Cell Work

Secondary Phone: Home Cell Work

E-mail address: Fax:

PET INFORMATION

Pet’s Name: Breed: Color: Date of birth: Age: Weight:

Sex: Male (intact) Male (neutered) Female (intact) Female (spayed)

Age Obtained: Age neutered or spayed: Declawed? Yes No

Where did you obtain this cat?

BREEDER FRIEND PET STORE ANIMAL SHELTER RESCUE OTHER

Behavior problems of parents or littermates, if known:

VETERINARY INFORMATION

Your primary veterinarian’s name:

Note: After any behavioral consultation, we will send a discharge summary to your veterinarian.

Name of Clinic or Hospital:

Street Address:

City: State: Zip:

Office Phone: Fax:

How did you learn of the NCSU Behavioral Medicine Service?

PART II. PRINCIPAL BEHAVIORAL COMPLAINT

Summarize the primary behavior problem in one sentence:

How would you describe the severity of this problem? MILD MODERATE SEVERE

What is your primary goal in coming to see the NCSU Behavior Service?

Have you considered euthanasia? YES NO Please comment:

Describe the last two incidents in as much detail as possible.

1.  Date: Incident:

2.  Date: Incident:

FREQUENCY

Please indicate the number of times the problem has occurred in each of the times indicated.

Past Week / Past Month / Past Year / Total Number of Times
No. of Times

PART III. HOUSEHOLD INFORMATION

PERSONS LIVING IN THE HOUSEHOLD

List each person living in the household, including age, sex, hours away from home, and comment on each person’s relationship with your pet.

Name / Age / Sex / Hours Away / Relationship with pet
M F
M F
M F
M F
M F

PETS LIVING IN THE HOUSEHOLD

List all other pets in household. Comment on the relationships between the pets.

Name / Species / Breed / Age / Sex / Weight / Relationship with patient pet

PART IV. BACKGROUND INFORMATION

Question / Your Response
At what age was your pet when the problem began?
Were there changes in the home at that time?
List techniques you have used to address the problem.
Put (+) next to techniques that seem to have helped.
Put (-) next to techniques that made things worse.
Put (0) next to techniques that had no effect. / 1.
2.
3.
4.
Additional techniques:
Have any drugs or remedies been tried for this problem? Please list.
Put (+) next to techniques that seem to have helped.
Put (-) next to techniques that made things worse.
Put (0) next to techniques that had no effect. / 1.
2.
3.
4.
Additional:
What do you think is the reason for your cat’s problem?

CORRECTIONS

Indicate any correction techniques you have used and indicate the effects on your cat’s behavior.

Type of Correction / Have you Tried? / Improved the Problem / No Effect on the Problem / Made the Problem Worse
Time out / Yes No
Verbal Scolding / Yes No
Spanking / Yes No
Noisemaker / Yes No
Water bottle/sprayer / Yes No
Lifting by the scruff / Yes No
Other (describe) / Yes No

PART V. HOME ENVIRONMENT

Briefly describe home: House Townhouse Apartment Other Number of floors:

How long have you lived in this location?

Does your cat ever go outside? YES NO If so, when?

DIET

Food/Treat / Brand name / How often given? / Desire for this food type
Cat food (canned) / mild moderate strong
Cat food (dry) / mild moderate strong
Other food / mild moderate strong
Treats / mild moderate strong
Supplement/Vitamin / mild moderate strong

PART VI. BEHAVIORAL PROFILE

HANDLING

Check how your cat responds to the following tasks:

TASK / NO REACTION / AVOIDS / RESISTS / GROWLS or BITES / FAVORS, PURRS / COMMENTS
Greeting you
Greeting stranger
Petting/stroking
Grooming
Being picked up
Bathing
Trimming nails

Are you able to medicate your cat yourself? YES NO

What is the best way for you to give your cat medication?

PART VII. AGGRESSION

Are you having a problem with aggression in your cat? YES NO

If you answered NO, please skip this section and proceed to Section VIII.

TARGET: To whom is the aggression directed? PEOPLE OTHER CAT(S) BOTH

RESPONSE

Indicate your cat’s response to the following situations. Check all that have ever applied.

Task / No Response / Hisses / Meows / Snarls / Bites
When cat is approached by person
When cat is picked up
When cat is petted/groomed
When cat is scolded or spanked
When cat sees other cat in the household
When cat sees other cat that is outside
To restraint (ex: at veterinarian’s)
To painful stimuli (ex: injection by veterinarian)
Other (describe)

Has your pet been reported to animal control authorities or a public health department for biting? YES NO

Is your pet currently in 10-day quarantine for biting? YES NO

PART VIII. HOUSE-SOILING

Are you having a house-soiling problem with your cat? YES NO

If you answered NO, please skip this section and proceed to the Section IX.

House-soiling problem related to: URINE FECES BOTH

Have you ever seen your cat spray urine? YES NO UNCERTAIN

How often (per day or per week) do you detect urine or feces outside the litter box?

“CULPRIT”:

If you have more than one cat, which of your cats is house-soiling?

How do you know this cat is the “culprit”?

LOCATION:

In what room or rooms does your cat house-soil?

In what room or rooms (to which your cat has access) does house-soiling NEVER occur?

SUBSTRATE:

What is your cat’s favorite “surface” for house-soiling (ex: carpet, throw rugs, bed, laundry, other):

TEMPORAL PATTERN:

What time of day is your cat most likely to house-soil?

LITTER BOX DATA

Litter Box Information / Response
Number of litter boxes in your home
How often are litter boxes scooped out?
What type of litter box or boxes do you use (ex: plain, covered, or electronic)?
What type of litter do you use? Include type (ex: clay, clumping, newspaper) and brand.
Have you tried other litters?
If so, which types and brands? / YES NO
Types/brands tried:
Do you use a litter box liner? / YES NO
Does your cat dig in the litter box before or after eliminating? / YES NO
Does your cat bury urine/feces (at least some of the time) after using the litter box? / YES NO

IX. MEDICAL HISTORY

Is your pet up to date on routine vaccinations, including rabies? YES NO

MEDICATION

Indicate any medication your cat currently receives:

Name of Medication / Dose (mg) or amount / How often? / Reason Given?

MEDICAL PROBLEMS

Please list any medical problems your pet has had.

Problem / Dates if known / On going?
YES NO
YES NO
YES NO
YES NO

Thank you for taking the time to fill out this form.

Revised 7.5.2011

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