Testing Feline Consultation QuestionnaireOwner InformationName:Address Street Address City State / Province / Region Home PhoneCell PhoneEmployer’s name:Employer’s Address Street Address City State / Province / Region ZIP / Postal Code Work PhoneEmail Preferred local pharmacy:Preferred local pharmacy: NamePreferred local pharmacy: Phone#Preferred local pharmacy: Fax#Basic Feline InformationFeline’s name:Age:Breed:Color:Gender:MaleFemaleSpayed or neutered:SpayedNeuteredAge when performed:Weight: lbs or KgDate and age when acquired (if known):Date AgeSource:BreederShelterStrayRescueOther:Reason for obtaining this cat:Litter size (if known):Age when weaned (if known):Bottle fed:YesNoDescribe your cat’s personality:Has your cat been bred?YesNoHas 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?YesNoFeline Medical History *Please ensure that we have all your pet's medical recordsFamily veterinarian/Clinic namePhonePrimary veterinarian:Clinic name:PhoneFax:Date of last veterinary visit: The most recent set of vaccinations received and date ( select all that apply ) :VaccineDate VaccineDate VaccineDate Other:Date Date wormed: Referred by:Provide medical history (infection/surgeries) and prescribed treatment: HistoryTreatment:HistoryTreatment:HistoryTreatment:HistoryTreatment: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?DrinkingYesNoDetailsEatingYesNoDetailsDetails:Details:Have you noticed any of the following?CoughingSneezingVomitingDiarrheaHas your cat ever been treated for its behavior in the past? If so, describe the treatment and medication (if applicable):YesNoIf so, describe treatmentMedications :Dose :Medications :Dose :Medications :Dose :Medications :Dose :Does your cat have seizures or has it ever had any seizures?YesNoVeterinarian Notes:Current Human Household MembersYourselfAge:Occupation:Other Household PetsHave you owned cats previously?YesNoHave you owned this breed of cat previously?YesNoHave you owned other pets previously?YesNoCurrent pets in the household :Type and breedNameAgeSpayed or neuteredYesNoRelationship with cat (fight, play, avoid)Diet and Feeding Habits:Type(s) of food:DryCannedBothAgeBrand(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:GoodAveragePoorAt what speed does it typically eat?FastSlowDo you have to be present for your cat to eat?YesNoWhat 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:YesNoDetails :DetailsVeterinarian 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?YesNoIf yes, how often and do you have any idea why? How oftenDoes your cat seek out high places to rest?YesNoWhere can your cat normally be found during the day?Is your cat allowed to go outside?YesNoIf 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 accessFree access through cat doorHow often do you see other cats in your yard?DailySeveral times per weekIs the yard fenced?OccasionallyRarelyNeverWhat area is available for the cat to roam outside?How far does your cat roam on average?It stays in the yardIt may go next door or two doors awayI do not know how far it roams when outsideHave 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?YesNoHow many litter boxes are provided?Has there been a change in the number of litter boxes provided?YesNoIf yes, how recently?From how many, to how many? From toWhere are the litter boxes located? *Mark or indicate their location on the included mapHas there been a change in litter-box location?YesNoIf yes, how recently?From where, to where? From toWhat types of litter boxes are provided?CoveredUncoveredBoth are providedDescribe the shape and size of each box:What type and brand of litter is used?Are odor-control granules added?YesNoHave you changed the litter material brand or type?YesNoIf yes, how recently?From what, to what? From toHow 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?YesNoIf yes, how recently?From what, to what? From toWhat do you use to clean and wash the actual box?Does the cat use the litter box on a regular basis?YesNoHow many times per day does it use the box? times per dayDoes the cat use the litter box for:Urine onlyFeces onlyBothNeitherDoes the cat bury its urine?YesNoDoes the cat bury its feces?YesNoIs there much digging and scratching in and around the litter box?YesNoVeterinarian Notes:Problem elimination behavior (if applicable)What is the cat leaving outside the litter box?Urine onlyFeces onlyBothHow often does this occur?Once a weekOnce a monthOnce a dayAlwaysHow 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?RoomLocationsNo. of depositsRoomLocationsNo. of depositsRoomLocationsNo. of depositsMark 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)?YesNoPlease explain :Have you ever caught the cat depositing urine or feces outside the litter box?YesNoIf yes, what was your response?What was the cat’s response?What posture does the cat assume when eliminating outside the litter box?Standing uprighSquattingWhere is the urine located?On the floorOn the walls, 6–8 inches above the floorIs the cat spraying or urinating?SprayingUrinatingDoes the cat have a history of urinary tract infections?YesNoIf you are not the cat’s first owner, did the cat have similar issues in its previous home(s)?YesNoN/ADon’t knowWhen 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?YesNoIf yes, please specifyVeterinarian Notes:Territorial BehaviorDoes your cat defend its territory against other cats?YesNoIf so, which cats?Unfamiliar cats outsideHousemates: NamesDescribe your cat’s appearance when defending its territory Details:Does your cat fight with any of the other cats in the home?YesNoNameDoes your cat catch prey and bring it into the house?OccasionallyRegularlyNeverDo you ever see another housemate cat physically blocking this cat from accessing food, litter boxes, rooms, toys, or climbing perches?YesNoNameDo you ever see this cat physically blocking a housemate cat from accessing food, litter boxes, rooms, toys, or climbing perches?YesNoNameWhat type of prey does it catch?Veterinarian Notes:Play BehaviorIs your cat playful?YesNoIs there any specific time devoted to play or training on a daily basis?YesNoDoes your cat play games with you or with other family members?YesNoIf yes, provide details:Who initiates play?CatFamily membersWhat types of toys does your cat play with?StringFeathersBallsLaserOtherIf 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?CrateSpecified roomFree run (in house)OutsideOtherWhat 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?YesNoHas your cat been declawed?Front two pawsAll four pawsAt what age was your cat declawed?Do you have one or more scratching posts for the cat?YesNoDescribe the type and location of the post(s):Does your cat use the scratching post(s)?YesSometimesNeverMy cat scratches on other thingsVeterinarian Notes:Interaction With Family MembersWhat type of home do you have?ApartmentHouseCondoTownhomeOtherIf other, provide details:How would you describe your home?QuietLivelyChaoticTo 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:FoodWaterLitter boxesRest areasClimbing towersScratching postsWindowsReaction 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/groomingYesNoN/APetting, hugging, or holdingYesNoN/ADisturbed when restingYesNoN/ADiscipliningYesNoN/APlayingYesNoN/AGiving treatsYesNoN/APutting the cat in the carrierYesNoN/AAdult owner #2 Name:Brushing/groomingYesNoN/APetting, hugging, or holdingYesNoN/ADisturbed when restingYesNoN/ADiscipliningYesNoN/APlayingYesNoN/AGiving treatsYesNoN/APutting the cat in the carrierYesNoN/AChildrenBrushing/groomingYesNoN/APetting, hugging, or holdingYesNoN/ADisturbed when restingYesNoN/ADiscipliningYesNoN/APlayingYesNoN/AGiving treatsYesNoN/APutting the cat in the carrierYesNoN/AAny other specific individual Name:Brushing/groomingYesNoN/APetting, hugging, or holdingYesNoN/ADisturbed when restingYesNoN/ADiscipliningYesNoN/APlayingYesNoN/AGiving treatsYesNoN/APutting the cat in the carrierYesNoN/AVeterinarian 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?YesNoIf yes, provide details:Is your cat quick to approach new people?YesNoHas your cat ever bitten anyone?YesNoIf 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 menInside Details:Outside Details:Familiar womenInside Details:Outside Details:Familiar childrenInside Details:Outside Details:Unfamiliar menInside Details:Outside Details:Unfamiliar womenInside Details:Outside Details:Unfamiliar childrenInside Details:Outside Details:Familiar catsInside Details:Outside Details:Unfamiliar catsInside Details:Outside Details:Other animals (e.g., dogs, squirrels)Inside Details:Outside Details:Crowds and busy areasInside 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?YesNoIf yes, describe this behavior:Does your cat ever show inappropriate mounting or other sexual behaviorYesNoDetails :Does your cat tolerate, enjoy, or resist the following?GroomingTolerateEnjoyResistHandlingTolerateEnjoyResistDoes your cat lick or chew itself more than you would expect?YesNoIf 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?YesNoIf 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?ChronicIntermittentHow 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?BetterWorseNo changeDo 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?YesNoIf 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:YesNoDetails of punishment :Was there a bite or scratch wound?PunctureTearScratchesDescribe the previous three incidents prior to the most recent incident:How frequently does this type of incident occur?Several times a dayDailySeveral times a weekWeeklyMonthlyOtherDoes this problem occur when the cat is left alone?AlwaysSometimesNeverDoes this problem occur when family members are present?AlwaysSometimesNeverWhat has been done to correct the problem?Is the problem getting better or worse?BetterWorseNo changeDo you suspect any cause?Veterinarian Notes:Relationship with FelineHow would you describe your own and your family’s relationship with this cat?Adult owner #1Adult owner #2ChildrenWhat are your own and your family’s feelings about the cat’s present behavior?Adult owner #1Adult owner #2ChildrenWhat 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: This iframe contains the logic required to handle Ajax powered Gravity Forms.