New Cat (Feline) Questionnaire

The Pet Agency

5633 Kenneth Avenue

Carmichael, CA 95608

Telephone/Text: 916-968-3111

E-mail: michelle@thepetagency.com


Cat Owner Information:

Name:

Address:

Phone (home) (work) (cell)

Email:


Veterinarian Information:

Clinic Name:

Doctor's Name: Phone:

Who referred you to the Behavior Service?


Cat Information:

Name: Breed:

Date of Birth/Age Weight Color

Sex: Male Female Neutered/Spayed: Yes____ No____

Date of last Rabies vaccination: ______________________ 1 Year 3 Year



People living in household:

Name

Age

Relationship (e.g. spouse, son, daughter, roommate, etc.)



















Other people in regular contact with pet (e.g. petsitters, housekeepers, friends, etc.):

Name

Age

Relationship (e.g. pet sitters, friend, grandchild, etc.)



















Pets in household (in order came into household). Please put an “X” next to the patient:

NAME

SPECIES/

BREED

AGE

NOW

SEX-

Neutered

AGE ACQUIRED



























Other pets in household (in order came into household):

Name

Species (e.g. dog, cat) &Breed (e.g., Golden Retriever, Manx)

Male/Female

Spayed/Neutered

Age Now

Age when obtained






































List any major household changes since acquiring this cat (e.g. moves, illness/death of pets/people, added new people/pets to the household, etc., etc.)

Date: Event:

Date: Event:

Date: Event:


Acquisition Information:

How old was this cat when acquired? _______________________________________________

Where did you obtain this cat? (Ex: Breeder) ___________

Private home/previous owner Shelter/rescue organization Pet store

Other


Behavior of cat’s parents/littermates (if known):


Describe previous home(s) (if known):


Why did you choose this cat?



Have you had other cats before: grew up with as an adult

Type of Home: Apartment Condo Private House



Medical History:

List any major illnesses/surgeries (dates):





List all medications/treatments your cat is currently receiving including heartworm, flea preventative, dietary supplements, herbal/homeopathic treatments:

Name of medication

Dosage/frequency given

Date started medication






























Daily Activities and Routine:

Feeding:

When and where is the cat fed?

Who feeds?

Types of food: Dry (BRAND) % of diet

Canned (BRAND) %of diet

Raw % of diet

People food % of diet

Other % of diet

Eating habits (check all that apply):

Eats right away Picky eater Anxious eater Guards food from people

Guards food from cats________Other

How long is food available N/A (eats immediately)

Average Day:

Does your cat go outside: No Yes

If yes, how much time does s/he spend outside daily?

Where?


Litterbox information:

Number of litterboxes in house

Location(s):






Type (and # of each type if applicable) of box(es):

Covered Uncovered

Size of box(es):




Type(s) of litter used: Clay Clumping/scoopable

Crystals Pellets (pine, wheat, etc)

Other

How often is the box scooped out?




How often is the box emptied and cleaned out?




What do you use to clean the box?





Describe a typical 24 hour day in your cat’s life, starting with when and where the cat wakes up in the morning. Include feeding, exercise and play times. If behavior problems occur at particular times of the day include that information.








Has your cat ever nipped or bitten a person? No Yes

If yes, describe the victim(s) (age, gender, actions e.g. 10 year old boy waving stick). Continue on additional pages if needed


Primary Behavior Problem:

What is the ONE main behavior problem you wish to address?


Describe the VERY FIRST incident of this problem

Try to remember the earliest occurrence of the problem, even if it wasn't as serious as it is now. For instance, if your cat is aggressive to people, describe the first time she growled at someone, not the first bite. Or if your cat has litterbox problems, describe the first time it happened.


Include where the incident occurred, who else (human and animal) was present, what happened just before the incident, how everyone present reacted.

Date of event Cat’s age (Approximate date/age is o.k.)








Describe per instructions above the most recent incident

Date of event Cat’s age







Describe per instructions above at least one other incident you feel illustrates the problem behavior (if you would like to describe other incidents please do so on a separate page)

Date of event Cat’s age







If you noticed any changes in your cat’s body language or facial expression before, during or after the incidents please describe.







Frequency:

How frequently does this problem occur?

>10 times/day_____ 1-10 times/day_____ 1-6 times/week_____ <1x/week_____ <1time/month___


Is the frequency… Increasing_____ Decreasing_____ Unchanged_____









What percent of time that your cat is in a potentially problematic situation does the problem behavior occur?:

<25% 25-50% 51-75% 76-100%


Describe what you've tried to correct the problem and what the cat’s response has been to each attempt.






How serious do you and other members of the household find this problem:

Name Mild Moderate Severe Intolerable

Name Mild Moderate Severe Intolerable

Name Mild Moderate Severe Intolerable



Has anyone suggested you euthanize or rehome this cat because of this problem? Y N

Have you ever considered euthanasia or rehoming this cat because of this problem? Y N



List other problem behaviors in order of importance to you.

Please include on a separate page a floor plan sketch of where your cat lives. Include in the diagram the location of: litterbox(es), food dishes, and mark with an “x” areas where the problem behavior occurs.


LIABILITY:


Pet (Dog) Owner’s Name(print name):


Pet’s Name:



I (pet owner), (enter name--→)

have read the policies and procedures put forth above and understand them fully. I agree to adhere to these policies as a client of The Pet Agency.



Pet Owner Signature:


Date:



Pg. 12/12