Feline Behavior Questionnaire Pet Parent InformationFirst and last name:(Required) Address:(Required) Primary phone number:(Required)Email:(Required) List all veterinary clinics your pet has visited in the past 5 years:Who referred you to the behavior service? Please list the names of anyone we have permission to speak with regarding your pet, including any family members who will not be present at the initial consultation. We may only discuss your pet with their primary care veterinarian, others require written authorization. Pet InformationPet name: Breed: Color: Date of birth/Age: Sex: Spayed/Neutered: Yes No Age of spay/neuter: Declawed? Yes No Where and when did you get your cat? Has your cat had other (human) parents prior to living with you? Yes No Do you have information about your cat's history before you acquired them? If so, please explain.What are your goals for this appointment?List any existing health issues your pet has, including allergies or sensitivities:What do you feed your pet? What do you love the most about your cat? Recent research has shown connections between gut health and brain health. Please mark how often your cat has any of the following signs:Vomiting Daily Weekly Monthly Occasionally Rarely Diarrhea Daily Weekly Monthly Occasionally Rarely Constipation Daily Weekly Monthly Occasionally Rarely Decreased appetite Daily Weekly Monthly Occasionally Rarely Excessive licking Daily Weekly Monthly Occasionally Rarely Lip licking Daily Weekly Monthly Occasionally Rarely Environmental InformationHow many adults are in the household?Are there any children, elderly members, or immunocompromised individuals in the household or who visit regularly? Yes No Check all that apply to your pet’s environment: Indoor only Indoor/outdoor Outdoor only Access to screened patio Supervised outdoor time How many play sessions does your cat get per day?List any other pets in the household and their relationship with the patient:Check all of the following that your cat has access to: Designated scratchers Climbing areas Hiding areas away from people and other pet Toys for play alone Litter BoxesPlease complete the following regarding each litter box in your household.Litter box 1: Covered Uncovered Self-cleaning/electronic Liner What size is litter box 1? What type of litter is in litter box 1? Where is litter box 1 located? Litter box 2: Covered Uncovered Self-cleaning/electronic Liner What size is litter box 2? What type of litter is in litter box 2? Where is litter box 2 located? Litter box 3: Covered Uncovered Self-cleaning/electronic Liner What size is litter box 3? What type of litter is in litter box 3? Where is litter box 3 located? Litter box 4: Covered Uncovered Self-cleaning/electronic Liner What size is litter box 4? What type of litter is in litter box 4? Where is litter box 4 located? Litter box 5: Covered Uncovered Self-cleaning/electronic Liner What size is litter box 5? What type of litter is in litter box 5? Where is litter box 5 located? How often are the litter boxes scooped? How often are the litter boxes completely emptied and washed? Presenting ConcernsList the first concern for which you are seeking help: Age problem 1 started? Unknown Less than 4 months old 4 to 12 months old 1 to 3 years old 3 to 7 years old 7 years old or later Frequency of problem 1? Always Sometimes Rarely Never Has problem 1 gotten: Better Worse Unchanged Describe the most recent 2 incidents of this problem: List the second concern for which you are seeking help: Age problem 2 started? Unknown Less than 4 months old 4 to 12 months old 1 to 3 years old 3 to 7 years old 7 years old or later Frequency of problem 2? Always Sometimes Rarely Never Has problem 2 gotten: Better Worse Unchanged Describe the most recent 2 incidents of this problem: List the third concern for which you are seeking help: Age problem 3 started? Unknown Less than 4 months old 4 to 12 months old 1 to 3 years old 3 to 7 years old 7 years old or later Frequency of problem 3? Always Sometimes Rarely Never Has problem 3 gotten: Better Worse Unchanged Describe the most recent 2 incidents of this problem: Previous TreatmentsCheck all previous treatments that have been tried: Medications Supplements Avoidance Acupuncture Feliway product CBD product Clicker training Food toys (puzzle feeders, Kong) Hand feed/remove bowl while eating Hit or swat Hold down Increased play/exercise Loud noise (yelling, air horn, penny can) Obedience training Pressure wrap/Thundershirt Stare down Time out Treats or food rewards Water pistol/bottle Other Other treatment: Sleep BehaviorsDoes your pet sleep through the night? Yes No Have there been any changes in your pet’s sleeping patterns in the past 3 months? Yes No Does your pet take naps during the day? Yes No Elimination BehaviorsIf your cat eliminates or defecates outside of the box, please fill out the following questions. If not, move on to Fearful Behaviors.What does your cat do outside of the box? Urinate Defecate Both How often does your cat eliminate outside of the box? Always Daily Several times per week Weekly Monthly Every few months Check all that apply to your cat’s behavior when using the litter box: Covers urine Covers feces Scratches before eliminating Scratches sides of box Scratches outside of box Squats to urinate Stands to urinate Stands or perches on side or next to box Immediately uses a box after it is cleaned Vocalize Run out of box when finished When your cat eliminates outside of the box, check all that apply: Stands and sprays urine Urinates on horizontal surface Urinates on vertical surface Urinates a small amount Urinates normal/large amount Scratches as if to cover Eliminates on hard surfaces Eliminates on soft surfaces Eliminates in a specific spot What do you use to clean soiled areas? List all that you have tried.Fearful BehaviorsCheck all that apply to your cat’s behavior when you have visitors: Hides Cries/howls Eliminates outside of litter box Destruction Runs away Hisses Growls Swats/scratches Puffs up Stalks Bites Check all that apply to your cat’s behavior when another cat in the home is nearby: Hides Cries/howls Eliminates outside of litter box Destruction Runs away Hisses Growls Swats/scratches Puffs up Stalks Bites Check all that apply to your cat’s behavior when there is a new item in the home: Hides Cries/howls Eliminates outside of litter box Destruction Runs away Hisses Growls Swats/scratches Puffs up Stalks Bites Check all that apply to your cat’s behavior when an unfamiliar animal is nearby: Hides Cries/howls Eliminates outside of litter box Destruction Runs away Hisses Growls Swats/scratches Puffs up Stalks Bites Aggressive BehaviorsAggression describes a behavior, but it is not a personality trait. Aggressive behaviors include growling, hissing, swatting, scratching, and biting. If your cat has exhibited these behaviors in some situations, please answer the following section. If not, continue to the next section. These answers help your pet’s doctor appropriately diagnose and determine the best treatment plan for your cat. Has your pet ever bitten at a person (this includes an air snap)? Yes No Number of bites to a person: 1 2 3 4 5 or more Number of bites that broke skin: 1 2 3 4 5 or more Has your pet ever bitten at another cat (this includes an air snap)? Yes No Number of bites to a dog: 1 2 3 4 5 or more Number of bites that broke skin: 1 2 3 4 5 or more Has a bite ever been reported to public health authorities? Yes No Has there been any legal action regarding your cat's behavior? Yes No When is your cat aggressive? Around food Baths Collar or leash put on/taken off Corrected/scolded Eating Examined by vet Grooming (professional) Grooming (family) Hugged In their bed In person’s bed Nail trims Playing Picked up Reached for Spoken to Touched Startled Woken up Other What other time is your cat aggressive? Who is your cat aggressive toward: Familiar adults Unfamiliar adults Familiar children Unfamiliar children Familiar cats Unfamiliar cats Visitors to home Other pets in household Other animals outside home Wild animals Check all that apply to your cat’s body language when they are aggressive: Dilated pupils/glassy eyed Ears back Stiff body Growl Hair/hackles up Hiss Lip licking Lowered head Lowered body Lunge Tail thump Tail Twitch Tail curled tightly around body Turn head away Turn body away Try to escape Yawn Zone out Other Describe other body language when aggressive: Separation BehaviorsIf your pet exhibits distress when separated from you or left alone, please fill out the following section. If not, move on to Storms/Sound Behaviors.Behavior when you get ready to leave (check all that apply): Aggressive toward you Avoids being confined Attempts to escape Calm Hides Looks sad Follows you around Cries Other Other behavior when you get ready to leave: Behavior while you are gone or cannot be reached (check all that apply): Attempt to escape Defecate Destruction Hide Howl Pace Tremble Urinate Whine Other Other behavior when you are gone or cannot be reached: Does your cat exhibit this/these behavior(s) every time they are alone? Yes No Does your cat exhibit this/these behavior(s) when a certain person departs, but not others? Yes No Describe anything else you would like to share about your pet’s behavior when you leave: Storms/Sound BehaviorsIf your pet exhibits fear or stress related to storms or noises, please fill out the following section. If not, move on to Veterinary Visits.What sounds cause your cat to exhibit fear or stress (check all that apply): Traffic sounds Beeping Construction sounds Cooking sounds Doorbell Electronic alert sound Fireworks Rain Thunder Other Other sounds that cause your cat to exhibit fear or stress? What is your cat's body language in response to a scary sound (check all that apply): Aggressive when interacted with Pace Pant Destructive Drool Find person/family member Howl Tremble Try to escape room or house Try to hide Other Other body language in response to a scary sound? How long does it take your cat to calm down after sound/storm ends? Calms down while still happening Immediately 5-10 mins 11-20 mins 21-30 mins 31-45 mins 46-60 mins 1-3 hours 4-6 hours 7-12 hours 12-24 hours More than 24 hours Veterinary Visit BehaviorCheck all that apply to your cat in the veterinary office and during examination: Tremble Cower Hide Try to escape Hiss Pace Pant Freeze Ears back Growl Scratch/swipe Lunge Bite Tail wrapped tightly around body Tail twitch/thump Does your cat excessively groom themselves? Yes No Have euthanasia or rehoming been recommended or considered prior to your visit with us? Yes No Medical Records Please have your veterinarian and any specialists your pet has seen send us your pet’s medical records, including any lab work. Documents can be uploaded below or sent by email to petshrink@pazvet.com or by fax to 512-481-7071 The Day Of: Please schedule a consult for all pets that are involved in the problem if you can do so safely. If multiple pets are involved and only one pet can come to the appointment, then the doctor may recommend a consult for your other pet(s) to adequately treat the problem. Please bring your pet's favorite toys and treats with you to the appointment so that we can use those items during your pet's appointment, if appropriate. Photos and Videos Videos of problem behaviors may be helpful. Do not under any circumstance invite or trigger aggressive behavior for the purpose of a video. Please limit videos to 2 minutes or less so they can be quickly added to your pet’s medical record. File Uploads Drop files here or Select files Max. file size: 50 MB. Please be patient and allow all files to upload prior to continuing.If you provide a video or pictures of your pet(s), would you give us permission to use them for teaching purposes in textbooks, publications such as journals, and during teaching presentations? Yes No Each pet is an individual, so results of behavioral therapy cannot be guaranteed. While improvement can be seen quickly, many emotional disorders are chronic in nature and require continued therapy. Response to therapy is dependent on the individual’s response and the implementation of the recommendations made by your pet’s doctor. The behavior service is unable to guarantee that a treatment plan will be able to completely remove a patient’s aggression or potential danger to people or other animals. Pets should always be managed in accordance with local ordinances and leash laws.By signing below, I acknowledge that:I am the legal owner of the pet seeking behavioral medicine treatment from the behavior service at PAZ Veterinary. Follow up appointments for behavior therapies range from every 4 to 6 weeks to every few months depending on the case.Fees are to be paid at time of service and I accept responsibility for all charges that I approve related to the treatment of my pet. I am seeking treatment by the behavior service with full knowledge of the above and of the liability associated with ownership of a pet that has exhibited aggression in the past. Signature