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Cat History Behavior Form

"*" indicates required fields

Step 1 of 6

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Client Information

Due to time constraints, during the appointment we will focus on one or two behavior problems. We can make note of other unwanted behaviors to address at a later date, but the initial consultation will be geared toward assessing, diagnosing, and explaining your options to improve your cats' main or most serious behavior problem. Your information is saved on our server as you enter it.
MM slash DD slash YYYY
Name*
Preferred Pronouns*

MM slash DD slash YYYY
Persons living in the household. List each person living in the household.*
Name
Age
Preferred Pronouns
Relationship to you
 
Address*

Cat Information

Note months and years if applicable.
Cat's Sex*
Is your cat spayed or neutered?*
in pounds
Declawed?*

Household Information

What type of residence do you have?*
What type of neighborhood do you live in?*
Is your cat*
Pets living in the household. (Comment on the relationship between the cat with the behavioral problem and your other pets: e.g. "get along" or "neutral" or "conflict")
Name
Species
Breed
Age
Sex
Spayed/neutered?
Relationship with patient? ONLY use "get along," neutral," or "conflict"
 

Medical History

Medication: Indicate any medication your cat currently receives (e.g., thyroid medication, fluoxetine, trazodone, etc.)
Name of Medication
Dose (mg) or amount
How often
When was it started
 
Medical problems
Problem
Dates, if known
Ongoing? Yes/no
 
How often does your pet perform the following? (Answer with: never, daily, weekly, monthly, or several times a year)*
Diarrhea/loose stool
Vomiting
Decreased appetite
Constipation
Excessive licking/grooming
Eating non-food items
 

General

Pet Acquisition Background

Primary Problem Statement

How have you addressed the problem so far?

Avoided exposure*
Treats*
Hired professional help*
Clicker training*
Increased play*
Spanking/pop on the nose*
Time out*
Verbal scolding*
Water bottle/spraying*
Sound/noisemaker*
Vibration/electric collar*
Adopt another pet*

Sleep

Does your cat sleep through the night?*

Litter Box Data

For each litter box, fill out the following data*
Type (covered, uncovered, automatic)
Location
Liner used? YES/NO
Does your pet urinate in this box? YES/NO
Does your pet defecate in this box? YES/NO
 
How often are the litter boxes scooped?*
Does your cat ever run out of the litterbox quickly as soon as they are done urinating or defecating?*
Does your cat stand on the edge of the box when urinating or defecating?*
Does your cat go in and out of the litterbox several times before urinating or defecating?*

General Behavior Towards Others

Check which triggers cause your pet to show aggression (any of the following behaviors: growling, barking, lunging, snapping, and/or biting) towards:*
Check which triggers cause your pet to show fear/anxiety (any of the following behaviors: cowering, retreating or hiding) towards/during:*
Has your cat ever bitten a person or another animal?*
If your cat has bitten a person, please describe.
Who
Trigger
What part of body
Did it break skin
 
If your cat has bitten another cat, please describe:
Who
Trigger
What part of body
Did it break skin
 
Has your cat been reported to animal control?*

House Soiling

Are you having a house-soiling problem with your cat?*
Have you seen your cat eliminate outside the box?*
When your cat soils, is it:*
Have you ever seen your cat spray urine (backing up to a vertical surface, tail raised, quivering, and ejecting urine behind them?*
Does house soiling occur right next to the litter box?*
Have you ever considered euthanizing your cat because of the behavior problem?*
Have you ever considered rehoming your cat because of the behavior problem?*

Client Service Agreement

All clients are informed of our policies via email. This information can also be requested by other means (mailing address, fax) if requested by the client. By signing this document and/or scheduling an appointment with the SF SPCA Behavior Specialty Service, clients are agreeing to comply with the service’s policies, protocols, and expectations. Results and progress may vary depending on various factors and are not guaranteed. Any photo or videos taken during the consultation may be used as part of your pet’s medical record.
We often utilize pictures and videos taken during the consultation or submitted to the SF SPCA Behavior Service in educational seminars and programs. Actual names of clients and patients are not used. Clients will not be entitled to inspect or approve the use of these pictures and videos, or receive notice of their use or publication, or receive any payment. Do you authorize the use of your pet’s pictures and videos?*
Do you authorize sharing medical records with veterinarians providing care to your pet?*
Do you authorize sharing medical records with trainers approved by our service that request patient information?*
Terms & Conditions*
I have read the policies and procedures put forth in the San Francisco SPCA Behavior Service Agreement, and understand them fully. I agree to adhere to these policies as a client of the San Francisco SPCA Veterinary Hospital. By signing this document, I am confirming that I am at least 18 years of age, I am the legal owner of my pet(s) that are being evaluated, and that I agree to comply with the policies and terms explained in this document. I consent to and authorize the SF SPCA Behavior Specialty Service to treat my pet(s) and I assume financial responsibility for all related fees.
Clear Signature
Consent*
Clear Signature

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