X/TwitterThis field is for validation purposes and should be left unchanged.Name* First Last Pet’s Name*Pet’s Age*Today’s Date* MM slash DD slash YYYY How did you hear of Abbey Animal Hospital?*Breed*Birth date*Age obtained*Sex* M F Pregnant?* Yes No Spayed/Neutered?* Yes No If yes, at what age:Weight*Where did you obtain this pet:* Breeder Friend Pet Store Humane Shelter Rescue Behavior Problems of parents or littermates, if known*Your primary veterinarian’s name:Name of Clinic or HospitalPhonePrincipal Behavioral ComplaintSummarize the primary behavior problem in one sentence:*How would you describe the severity of this problem?* Mild Moderate Severe Have you considered euthanasia?* Yes No Please Comment:Describe the last two incidents in as much detail as possible. Include an approximate date of each incident:*FREQUENCYPlease indicate the number of times the problem has occurred in each of the times indicated below: PAST WEEK*PAST MONTH*PAST YEAR*Since you’ve owned*BACKGROUND INFORMATIONAt what age was your pet when the problem began?*Were there any changes in the home at that time?*List techniques you have used to correct the problem*TECHNIQUESWhat techniques (if any) have helped?*What techniques have made the problem worse?*Have any drugs been tried for this problem? If yes, what?*What do you think is the reason for your cat's problem?*PERONS LIVING IN THE HOUSEHOLDList each person living in the household, including age, sex, time away from home (example 9am-5pm), and comments on that person’s relationship with your pet (for exam: “feeds cat” or “is afraid of cat”)*(Please list the NAME, AGE, SEX, HOURS AWAY, RELATIONSHIP W/ Pet)PETS LIVING IN THE HOUSEHOLDList all other pets in the household. Comment on the relationship between the cat with the behavior problem and your other pets (for example: “get along” or “dominates cat.”)*(Please list the NAME, SPECIES, BREED, AGE, SEX, COMMENTS)DIETBrand Name (WET Cat FOOD )How Often Given (WET Cat FOOD )Desire For This Type Of Food (WET Cat FOOD) Mild Moderate Strong Brand Name (DRY Cat FOOD )How Often Given (DRY Cat FOOD )Desire For This Type Of Food (DRY Cat FOOD) Mild Moderate Strong Brand Name (ADDITIONAL Cat FOOD )How Often Given (ADDITIONAL Cat FOOD )Desire For This Type Of Food (ADDITIONAL Cat FOOD) Mild Moderate Strong Brand Name (TABLE SCRAPS / PEOPLE FOOD )How Often Given (TABLE SCRAPS / PEOPLE FOOD )Desire For This Type Of Food (TABLE SCRAPS / PEOPLE FOOD ) Mild Moderate Strong Brand Name (TREATS TYPE 1 )How Often Given (TREATS TYPE 1 )Desire For This Type Of Food (TREATS TYPE 1 ) Mild Moderate Strong Brand Name (TREATS TYPE 2 )How Often Given (TREATS TYPE 2 )Desire For This Type Of Food (TREATS TYPE 2 ) Mild Moderate Strong Brand Name (SUPPLEMENTS / VITAMINS )How Often Given (SUPPLEMENTS / VITAMINS )Desire For This Type Of Food (SUPPLEMENTS / VITAMINS ) Mild Moderate Strong LOCATION/ACTIVITY/EXERCISEAMOUNT OF TIME per DAY or PER WEEK CAT SPENDS at this Site/Activity (In HOUSE, PER DAY )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (In HOUSE, PER DAY )INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (In HOUSE, per day)AMOUNT OF TIME per DAY or PER WEEK CAT SPENDS at this Site/Activity (OUTSIDE PER DAY)INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (OUTSIDE PER DAY)INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (OUTSIDE PER DAY)AMOUNT OF TIME per DAY or PER WEEK CAT SPENDS at this Site/Activity (ALONE PER DAY)INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (ALONE PER DAY)INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (ALONE PER DAY)AMOUNT OF TIME per DAY or PER WEEK CAT SPENDS at this Site/Activity (PLAYTIME, per day )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (PLAYTIME, per day )INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (PLAYTIME, per day )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (Jogging or structured exercise, per week )INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (ASLEEP)INDICATE LOCATION (loose in house, in kitchen, in crate or pen, at park, ect.) (ASLEEP)INDICATE WHAT CAT WEARS (nothing, collar, harness, chock chain, prong collar, halter, ect.) (ASLEEP)What is your pet’s favorite toy?*What is your pet’s favorite game?*Are you able to medicate your cat yourself?* Yes No What is the best way for you to give your cat medication?*HANDLINGCheck how your cat responds to the following tasksNail Trim* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Greeting you* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Greeting Stranger* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Bathing* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Petting, Stroking* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Grooming* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*Being Picked Up* NO REACTION AVOIDS RESISTS GROWLS SNAPS Comment*CORRECTIONSIndicate any correction techniques you have used and indicate their effects on your cat’s behaviorTYPE of Correction ( Time Out )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Water Sprayer )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Verbal Scolding )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Noisemaker Shaker can/siren )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Lifting by Scruff )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse TYPE of Correction ( Spanking )* Yes No RESULT Improved the Problem No Effect on the Problem Made the problem worse Other TYPE of CorrectionHOUSE SOILINGAre you having a house-soiling problem with your cat?* Yes No Is the house-soiling problem related to:* URINE FECES BOTH Have you ever seen your cat spray urine?* Yes No How often are you finding 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 (i.e.: carpet, throw rugs, bed, laundry, etc…)*TEMPORAL PATTERN: what time of day is your cat most likely to house-soil?*LITTER BOX DATANumber of litter boxes in your home:*Number of litter boxes in your home:*How often are your litter boxes scooped? Completely changed?*What type of litter box(es) do you use? (i.e.: plain, covered, electronic)*What type of litter do you use? Brand and Type (i.e.: clay, clumping, newspaper)*Have you tried other litters? If so, which type and brand?*Do you use a litter box liner?*Does your cat dig in the litter box BEFORE eliminating?*Does your cat bury urine and/or feces (at least some of the time) after using the litter box?*AggressionTARGET: To whom is the aggression directed?* PEOPLE OTHER CAT(S) BOTH When approached by person* No Response Hisses Meows Snarls Bites When picked up* No Response Hisses Meows Snarls Bites When petted/groomed* No Response Hisses Meows Snarls Bites When scolded or spanked* No Response Hisses Meows Snarls Bites When cat sees other cats in household* No Response Hisses Meows Snarls Bites When cat sees other cats outside To restrain (i.e. at veterinarians)* No Response Hisses Meows Snarls Bites OTHER (describe):Has your cat ever been reported to local authorities or public health department for biting?* Yes No Is your pet currently in a 10-day quarantine for biting?* Yes No Any other problems or issues you would like to go over with the Dr.?SYMPTOMSTECHNIQUES USED BEFORE TO RESOLVEOTHERMEDICAL HISTORYIs your pet up-to-date on routine vaccinations, including rabies?* Yes No Medication #1: NAME OF MEDICATION, DOSE (mg) or Amount, HOW OFTEN?, REASON GIVEN?Medication #2: NAME OF MEDICATION, DOSE (mg) or Amount, HOW OFTEN?, REASON GIVEN?Medication #3: NAME OF MEDICATION, DOSE (mg) or Amount, HOW OFTEN?, REASON GIVEN?OTHERMEDICAL PROBLEMS:Please list any medical problems your pet has had recently (within the last year or so)CHRONIC? Yes No PROBLEM? DATES IF KNOWN?CHRONIC? Yes No PROBLEM? DATES IF KNOWN?CHRONIC? Yes No PROBLEM? DATES IF KNOWN?CHRONIC? Yes No PROBLEM? DATES IF KNOWN?Please add any addition information or comments:
