Cat History Behavior Form

"*" indicates required fields

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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.

Today's Date*

MM slash DD slash YYYY

Name*

First Last

Preferred Pronouns*

She/her/hers

He/him/his

They/them

Other

Email*

Phone*

Client Birthday*

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*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cat Information

Cat's Name*

Cat's Breed*

Cat Color*

Cat's Age*

Note months and years if applicable.

Cat's Sex*

Female

Male

Is your cat spayed or neutered?*

Yes

Cat's Weight*

in pounds

Name of Regular Veterinarian

Phone Number of Veterinary Clinic

Email of Veterinary Clinic

How were you referred to us?*

Declawed?*

Front feet only

All four feet

Age at time of declaw*

Household Information

What type of residence do you have?*

Townhome

Condo

Apartment

Single-family home

What type of neighborhood do you live in?*

Urban

Suburban

Rural

Is your cat*

Indoor

Outdoor

Both

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

What is your primary goal for this appointment?*

Pet Acquisition Background

How old was your cat when you first acquired them?*

Where did you obtain your cat?*

Primary Problem Statement

In 2-3 sentences or bullet points, describe the main behavior problem that you would like us to help with.*

How old was your cat when the problem started?*

Do the behavior problems occur at particular times of the day or night? Please explain.

How have you addressed the problem so far?

Avoided exposure*

Yes

Treats*

Yes

Hired professional help*

Yes

Clicker training*

Yes

Increased play*

Yes

Spanking/pop on the nose*

Yes

Time out*

Yes

Verbal scolding*

Yes

Water bottle/spraying*

Yes

Sound/noisemaker*

Yes

Vibration/electric collar*

Yes

Adopt another pet*

Yes

If you are currently working with a trainer, please provide their name and contact information here

Please list all trainers you have worked with

Sleep

Does your cat sleep through the night?*

Yes

Litter Box Data

How many litter boxes are in the home?*

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?*

More than two times a day

Twice a day

Once daily

Every other day

Once a week

Less than once a week

Does your cat ever run out of the litterbox quickly as soon as they are done urinating or defecating?*

Yes

Does your cat stand on the edge of the box when urinating or defecating?*

Yes

Does your cat go in and out of the litterbox several times before urinating or defecating?*

Yes

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:*

Family members living in the home

Visitors

Children

At the veterinary clinic

Pets living in your home

Cats outside your home

Check which triggers cause your pet to show fear/anxiety (any of the following behaviors: cowering, retreating or hiding) towards/during:*

Family members living in the home

Visitors

Children

Pets living in your home

Cats outside your home

Veterinary clinic

Cat carrier

Car rides

Noises

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?*

Yes

House Soiling

Are you having a house-soiling problem with your cat?*

Yes

Have you seen your cat eliminate outside the box?*

Yes

When your cat soils, is it:*

Urine

Feces

Both

Have you ever seen your cat spray urine (backing up to a vertical surface, tail raised, quivering, and ejecting urine behind them?*

Yes

Uncertain

How often do you detect urine or feces outside the litter box?*

In what areas of your house does your cat soil?*

Does house soiling occur right next to the litter box?*

Yes

What is your cat's favorite "surface" for house soiling (e.g., carpet, rugs, bed, laundry)*

Have you ever considered euthanizing your cat because of the behavior problem?*

Yes

Any comments?

Have you ever considered rehoming your cat because of the behavior problem?*

Yes

Any comments?

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?*

Yes

Do you authorize sharing medical records with veterinarians providing care to your pet?*

Yes

Do you authorize sharing medical records with trainers approved by our service that request patient information?*

Yes

Terms & Conditions*

I understand and agree.

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.

Signature*

Consent*

I hereby confirm that I have read and agree to the cancellation policy, email policy, and refill policies for the SF SPCA Behavior Specialty Service. I understand that I may be charged a cancellation/reschedule fee if I fail to abide by the above cancellation policy. I understand that I may be charged an emergency refill fee if I request a refill be addressed within 48 hours.*

Signature*

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