Feline Consultation Questionnaire Owner InformationName:* Address Street Address City State / Province / Region Home Phone*Cell Phone*Employer’s name: Employer’s Address Street Address City State / Province / Region ZIP / Postal Code Work PhoneEmail* Preferred local pharmacy:Preferred local pharmacy: Name Preferred local pharmacy: Phone#Preferred local pharmacy: Fax# Basic Feline InformationFeline’s name:* Age: Breed: Color: Gender: Male Female Spayed or neutered: Spayed Neutered Age when performed: Weight: lbs or Kg Date and age when acquired (if known): Date MM slash DD slash YYYY Age Source: Breeder Shelter Stray Rescue Other: Reason for obtaining this cat:Litter size (if known): Age when weaned (if known): Bottle fed: Yes No Describe your cat’s personality:Has your cat been bred? Yes No Has your cat been bred? If so, at what age? How much interaction did the kitten have with people in the first year of life? What method of litter training was used? Your reaction to mistakes during litter training: Was there any interaction with other cats during the first year? If so, provide details: Are you the cat’s first owner? Yes No Feline Medical History *Please ensure that we have all your pet's medical recordsFamily veterinarian/Clinic name PhonePrimary veterinarian: Clinic name: PhoneFax: Date of last veterinary visit: MM slash DD slash YYYY The most recent set of vaccinations received and date ( select all that apply ) :Vaccine Date MM slash DD slash YYYY Vaccine Date MM slash DD slash YYYY Vaccine Date MM slash DD slash YYYY Other: Date MM slash DD slash YYYY Date wormed: MM slash DD slash YYYY Referred by: Provide medical history (infection/surgeries) and prescribed treatment: History Treatment: History Treatment: History Treatment: History Treatment: Current/ regular medications (Such as allergy, heartworm, herbal, over the counter, pain medication, supplements, topical flea and tick treatment ) :Medication : Dose : Route : Frequency given : Medication : Dose : Route : Frequency given : Medication : Dose : Route : Frequency given : Medication : Dose : Route : Frequency given : Has there been any change in the following?Drinking Yes No Details Eating Yes No Details Details: Details: Have you noticed any of the following?Coughing Sneezing Vomiting Diarrhea Has your cat ever been treated for its behavior in the past? If so, describe the treatment and medication (if applicable): Yes No If so, describe treatment Medications : Dose : Medications : Dose : Medications : Dose : Medications : Dose : Does your cat have seizures or has it ever had any seizures? Yes No Veterinarian Notes:Current Human Household MembersYourselfAge: Occupation: Other Household PetsHave you owned cats previously? Yes No Have you owned this breed of cat previously? Yes No Have you owned other pets previously? Yes No Current pets in the household : Type and breed Name Age Spayed or neutered Yes No Relationship with cat (fight, play, avoid) Diet and Feeding Habits: Type(s) of food: Dry Canned Both AgeBrand(s) ( e.g., Purina, Eukanuba, Friskies ) : Who is primarily responsible for the feeding? Name: How much food is given? Quantity of food: At what approximate time(s) of day is food given? Time of day: Where is the cat fed (physical location)? Where is the cat fed in relation to other cats in the household? Describe your cat’s appetite: Good Average Poor At what speed does it typically eat? Fast Slow Do you have to be present for your cat to eat? Yes No What are your cat’s favorite foods? How much water does your cat drink in a day (in pints or liters)? How many water bowls are provided? How much milk does your cat drink in a day (in pints or liters)? Do you add any supplements or tidbits to your cat’s diet? If so, provide details: Yes No Details : Details Veterinarian Notes:Daily ActivitiesWhere does your cat sleep at night? Where does your cat sleep during the day? When does your cat get up in the morning? Is your cat very active at night? Yes No If yes, how often and do you have any idea why? How often Does your cat seek out high places to rest? Yes No Where can your cat normally be found during the day? Is your cat allowed to go outside? Yes No If so, how long does it like to stay out for?How long in summer? How long in winter? Is access controlled by you or does the cat have free access through a cat door?Controlled access Free access through cat door How often do you see other cats in your yard? Daily Several times per week Is the yard fenced? Occasionally Rarely Never What area is available for the cat to roam outside? How far does your cat roam on average? It stays in the yard It may go next door or two doors away I do not know how far it roams when outside Have there been any changes in your household routine (e.g., new baby, change in working hours, moving, new roommate, visitors, dietary changes) or living arrangements? Details:Veterinarian Notes:Elimination BehaviorDo you provide a litter box? Yes No How many litter boxes are provided? Has there been a change in the number of litter boxes provided? Yes No If yes, how recently? From how many, to how many? From to Where are the litter boxes located? *Mark or indicate their location on the included map Has there been a change in litter-box location? Yes No If yes, how recently? From where, to where? From to What types of litter boxes are provided? Covered Uncovered Both are provided Describe the shape and size of each box:What type and brand of litter is used? Are odor-control granules added? Yes No Have you changed the litter material brand or type? Yes No If yes, how recently? From what, to what? From to How often is the waste material scooped out? How often is the litter box completely cleaned out and washed? Have you changed the scooping or cleaning frequency? Yes No If yes, how recently? From what, to what? From to What do you use to clean and wash the actual box? Does the cat use the litter box on a regular basis? Yes No How many times per day does it use the box? times per day Does the cat use the litter box for: Urine only Feces only Both Neither Does the cat bury its urine? Yes No Does the cat bury its feces? Yes No Is there much digging and scratching in and around the litter box? Yes No Veterinarian Notes:Problem elimination behavior (if applicable)What is the cat leaving outside the litter box? Urine only Feces only Both How often does this occur? Once a week Once a month Once a day Always How long has this behavior been going on? What time of day do you usually find the deposits outside the litter box (e.g., morning, afternoon, after work, overnight)? Where is the cat eliminating outside the box?Room Locations No. of deposits Room Locations No. of deposits Room Locations No. of deposits Mark or indicate the location on the included mapWhen the problem first began, can you recall any unusual incident occurring at that time or anything that might have upset the cat (e.g., new roommate, moving, change in working hours, addition of another pet, new baby, dietary changes)? Yes No Please explain : Have you ever caught the cat depositing urine or feces outside the litter box? Yes No If yes, what was your response? What was the cat’s response? What posture does the cat assume when eliminating outside the litter box? Standing uprigh Squatting Where is the urine located? On the floor On the walls, 6–8 inches above the floor Is the cat spraying or urinating? Spraying Urinating Does the cat have a history of urinary tract infections? Yes No If you are not the cat’s first owner, did the cat have similar issues in its previous home(s)? Yes No N/A Don’t know When was the last time a urine sample was examined by your veterinarian? What approaches (medical, environmental, or behavioral) have been used in the past to attempt to address the problem?Was any approach effective in decreasing or eliminating the problem behavior? Yes No If yes, please specify Veterinarian Notes:Territorial BehaviorDoes your cat defend its territory against other cats? Yes No If so, which cats? Unfamiliar cats outside Housemates: Names Describe your cat’s appearance when defending its territory Details:Does your cat fight with any of the other cats in the home? Yes No Name Does your cat catch prey and bring it into the house? Occasionally Regularly Never Do you ever see another housemate cat physically blocking this cat from accessing food, litter boxes, rooms, toys, or climbing perches? Yes No Name Do you ever see this cat physically blocking a housemate cat from accessing food, litter boxes, rooms, toys, or climbing perches? Yes No Name What type of prey does it catch? Veterinarian Notes:Play BehaviorIs your cat playful? Yes No Is there any specific time devoted to play or training on a daily basis? Yes No Does your cat play games with you or with other family members? Yes No If yes, provide details: Who initiates play? Cat Family members What types of toys does your cat play with? String Feathers Balls Laser Other If other, provide details: Does your cat come when called or do any tricks? How does your cat respond to catnip? Veterinarian Notes:Home AloneWhere does your cat stay during the day when no one is home? Crate Specified room Free run (in house) Outside Other What arrangements are made for the cat if you are away from home for some time (e.g., on vacation)? Details:Typically, how long is your cat left alone without human company on any given day? Veterinarian Notes:Scratching BehaviorHas your cat been declawed? Yes No Has your cat been declawed? Front two paws All four paws At what age was your cat declawed? Do you have one or more scratching posts for the cat? Yes No Describe the type and location of the post(s): Does your cat use the scratching post(s)? Yes Sometimes Never My cat scratches on other things Veterinarian Notes:Interaction With Family MembersWhat type of home do you have? Apartment House Condo Townhome Other If other, provide details: How would you describe your home? Quiet Lively Chaotic To which areas of your home does your cat have access? Please draw on a separate piece of paper a map or layout of your home with the following key areas clearly marked: Food Water Litter boxes Rest areas Climbing towers Scratching posts Windows Reaction to handling: Does your cat exhibit any aggression in the following circumstances? This can include growling, hissing, nipping, scratching, showing teeth, or biting. If biting occurs, please specify whether tear, puncture, or bruising is involved: Fill out the following tables depicting your cat’s typical reaction: In each box, describe the type of aggression (e.g., hissing, biting) that may be exhibited in each situation, even if it does not occur every timeAdult owner #1 Name: Brushing/grooming Yes No N/A Petting, hugging, or holding Yes No N/A Disturbed when resting Yes No N/A Disciplining Yes No N/A Playing Yes No N/A Giving treats Yes No N/A Putting the cat in the carrier Yes No N/A Adult owner #2 Name: Brushing/grooming Yes No N/A Petting, hugging, or holding Yes No N/A Disturbed when resting Yes No N/A Disciplining Yes No N/A Playing Yes No N/A Giving treats Yes No N/A Putting the cat in the carrier Yes No N/A Children Brushing/grooming Yes No N/A Petting, hugging, or holding Yes No N/A Disturbed when resting Yes No N/A Disciplining Yes No N/A Playing Yes No N/A Giving treats Yes No N/A Putting the cat in the carrier Yes No N/A Any other specific individual Name: Brushing/grooming Yes No N/A Petting, hugging, or holding Yes No N/A Disturbed when resting Yes No N/A Disciplining Yes No N/A Playing Yes No N/A Giving treats Yes No N/A Putting the cat in the carrier Yes No N/A Veterinarian Notes:Interaction With OthersHow does your cat behave when visitors come to the house (e.g., hides, shows interest in visitors, interacts with them)? Is the behavior different towards familiar and unfamiliar people? Yes No If yes, provide details: Is your cat quick to approach new people? Yes No Has your cat ever bitten anyone? Yes No If yes, and this is not the primary complaint at the present time, please provide brief details: Are there any regular visitors to the home? If so, please provide the information requested: Name: Purpose : Time and days : Cat’s reaction: What is your cat’s response to frequent, occasional, and rare visitors? Frequent visitors : Occasional visitors: Rare visitors : Cat’s reaction to :Inside the home :Outside the home :Familiar men Inside Details: Outside Details: Familiar women Inside Details: Outside Details: Familiar children Inside Details: Outside Details: Unfamiliar men Inside Details: Outside Details: Unfamiliar women Inside Details: Outside Details: Unfamiliar children Inside Details: Outside Details: Familiar cats Inside Details: Outside Details: Unfamiliar cats Inside Details: Outside Details: Other animals (e.g., dogs, squirrels) Inside Details: Outside Details: Crowds and busy areas Inside Details: Outside Details: Veterinarian Notes :Other BehaviorsWhen does your cat meow? When does your cat growl? When does your cat purr? Is your cat aggressive when it is denied something it wants? Yes No If yes, describe this behavior: Does your cat ever show inappropriate mounting or other sexual behavior Yes No Details : Does your cat tolerate, enjoy, or resist the following?Grooming Tolerate Enjoy Resist Handling Tolerate Enjoy Resist Does your cat lick or chew itself more than you would expect? Yes No If yes, provide details: How do you correct your cat when it misbehaves? Are there any other behaviors that you find objectionable, feel you should mention, or wish to discuss? Yes No If yes, describe these: Veterinarian Notes:The Current ProblemDescribe the problem you are currently experiencing with your cat : When did this problem begin? Did it coincide with any event or action that you can identify? Is this a chronic (constant) or intermittent problem? Chronic Intermittent How old was the cat when the problem began? Where does the problem commonly occur? With whom does it occur? How often does it occur? What approaches have been tried to correct the problem? Is the problem getting better or worse? Better Worse No change Do you suspect any cause? Describe the three most recent episodes of the behavior:Is there any legal action pending because of this cat’s behavior? Yes No If yes, please explain in detail: Veterinarian Notes:Aggression Section ( if applicable )Describe the most recent incident and the setting in which it occurred (be precise) : Where was the cat? Where was everyone else in relation to the cat? What was everyone doing prior to the incident? What was the cat’s body posture (position of ears, tail, face, fur)? What was your reaction or response? What was the cat’s response to your reaction? Was any form of punishment used? If so, give details: Yes No Details of punishment : Was there a bite or scratch wound? Puncture Tear Scratches Describe the previous three incidents prior to the most recent incident:How frequently does this type of incident occur? Several times a day Daily Several times a week Weekly Monthly Other Does this problem occur when the cat is left alone? Always Sometimes Never Does this problem occur when family members are present? Always Sometimes Never What has been done to correct the problem? Is the problem getting better or worse? Better Worse No change Do you suspect any cause? Veterinarian Notes:Relationship with FelineHow would you describe your own and your family’s relationship with this cat? Adult owner #1 Adult owner #2 Children What are your own and your family’s feelings about the cat’s present behavior? Adult owner #1 Adult owner #2 Children What is your expectation for change? Under what circumstances would you consider rehoming this cat? Under what circumstances would you consider relinquishing this cat to a shelter or rescue? Under what circumstances would you consider euthanasia? Veterinarian Notes:Video RecordingsVideo recordings of the specific problem behaviors are extremely helpful for verifying your descriptions. Never place any person or animal in danger in order to obtain video information. Feel free to bring the video recordings with you (on your phone, tablet, laptop, etc.) to your consultation. Please do not email videos ahead of time. Video number :Describe the scenario seen in the video :Veterinarian Notes:Video Notes:CAPTCHA
