VETERINARY BEHAVIOR CONSULTATIONS OF COLORADO
E’Lise M Christensen Bell, DVM DACVB
Ariel Fagen, DVM
21448 E Crestridge Pl
Centennial CO 80015
Phone (720) 306-9601 Fax (720) 306-9602
www.BehaviorVets.com Email BehaviorVets@gmail.com
FELINE BEHAVIOR HISTORY
Thanks to many behaviorists and, especially, the Animal Behavior Clinic at Cornell University for contributing to this history form.
* = required information
CLIENT INFORMATION
Primary Owner Name
Address 1
Address 2
City ST ZIP
Email Address
Phone(s)
Other Owner’s Name
Address 1
Address 2
City ST ZIP
Email Address
Phone(s)
Consultation Location (required for housecall)
Pet Name
Species
Breed
Age and DOB
Color
Male/Female
Neutered/Spayed
Last Weight and Date
Veterinarian
Clinic Name
Address 1
Address 2
City ST ZIP
Email Address
Phone
Req Data Entry
*
) ______-________  Cell
2nd: (
) ______-_________  Cell
1st: (
) ______-________  Cell
Same as above.
2nd: (
) ______-_________  Cell
1st: (
*
*
Cat
______Yrs
_____/_____/______
When adopted? ______________
 Male  Female
 Intact  Neutered/Spayed If so, at what age or when? __________
_______ lbs  kg
Date last weighed: _____/_____/______
Office: (
) ______-________
Fax: (
) ______-________
Referred by
v 1/26/2015
Page 1 of 28
BEHAVIOR CONCERN
*
Rank your cat’s behavior(s) of concern to you, how much of a problem you consider the behavior, and when you first noted.
 Very serious  Serious  Annoying First Noted:
1
2
 Very serious  Serious  Annoying First Noted:
3
 Very serious  Serious  Annoying First Noted:
4
 Very serious  Serious  Annoying First Noted:
5
 Very serious  Serious  Annoying First Noted:
Describe concerns in order of occurrence.
FIRST behavior incident you remember:
Date and time?
Who was present?
What occurred?
Cat’s body language – tail up/down, ears
Up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
MOST RECENT incident in same detail:
Date and time?
Who was present?
What occurred?
Cat’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
SECOND MOST RECENT incident in same detail:
Date and time?
Who was present?
What occurred?
Cat’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
THIRD MOST RECENT incident in same detail:
Date and time?
Who was present?
What occurred?
Cat’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
OTHER significant incidents:
Date and time?
Who was present?
What occurred?
Cat’s body language – tail up/down, ears
up/back, etc.?
Your response?
Any injuries – to whom, to what extent?
v 1/26/2015
Page 2 of 28
Describe the ranked concerns by intensity, frequency and your response.
Concern #1
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Concern #2
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Concern #3
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Concern #4
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Concern #5
How often do you note the behavior?
Daily  Weekly  Monthly 
How many times in that period do you
note the behavior?
1-2  3-5  6-10 
Has the problem changed in intensity?
Increased  No  Decreased 
In frequency?
Increased  No  Decreased 
How have you tried to correct this?
Did any techniques help?
Make the problem worse?
Note the various disciplinary techniques you
use for these behaviors and other problems.
v 1/26/2015
Page 3 of 28
HOUSEHOLD
*
Name any people living in your household.
Age
Name the other animals in the house in the
sequence obtained.
Species
Occupation
Relationship to each other
Breed
Age at
adoption
Hrs away
from home
Age now
Describe your cat’s relationship with the other
animals, i.e., friendly, hostile, fearful, etc.
Describe the locale where your cat spends
most of his/her time.
Describe the type of dwelling where your cat
spends most of his/her time.
*Include a floor plan of each level of the main
residence.
Describe the location and floor plan of any
secondary residence/vacation home.
City/town
 Suburbs
Rural
Studio/
1 BR
2 BR Apt/
condo
Townhouse House/
duplex
trailer
Ranch/
Farm
If your cat travels frequently, describe the
method of travel and how tolerated.
How many times have you moved since
acquiring your cat?
Describe changes in environment.
Describe how your household, including
people/animals, has changed since acquiring
your cat.
v 1/26/2015
Page 4 of 28
CAT’S BACKGROUND
Why did you decide to get a cat?
Have you owned cats before?
Why did you choose this breed, sex, color?
Where did you get this cat?
*
 Shelter/
rescue
 Stray
 Friend
 Newspaper  Serious
 Pet store
Breeder
 Breeder
 Backyard
Referral
Breeder
_____Yrs
 Yes  No
If so, describe.
Other – describe.
If known, how many littermates?
Male/female?
How many did you choose from?
Specifically, why this cat over others?
Describe any temperament test or behavioral
evaluation performed.
Describe your cat’s behavior as a kitten.
Favorite time and activity to share?
Best behavior performed?
Has the cat had other owners?
How many?
Why was the cat given up?
If your cat is intact, has he/she ever been bred?
Are you planning to breed?
If you have an intact female, when was her last
heat? Was it normal?
At what age was your cat neutered/spayed?
Were there behavior changes after neutering?
v 1/26/2015
Page 5 of 28
MEDICAL HISTORY
Previous Illness/Injury
*
Date of onset Date resolved
Has your cat ever been diagnosed with a
seizure disorder?
Does your cat have any problems with skin or
ears, i.e., scratching, redness, greasy, hair loss,
etc.?
 Yes
 No
If so, describe:
 Yes
 No
If so, describe:
Has your cat ever been diagnosed with any
bone or muscle problems?
Does your cat have chronic sneezing or
coughing?
Does your cat have periodic diarrhea or
gastrointestinal distress?
Medications used for MEDICAL problems past
or present
 Yes
 No
If so, describe:
 Yes
 No
If so, describe:
 Yes
 No
If so, describe:
Medications and doses used
Dose and frequency
Date begun/
ended
Side-effects
Medications used for BEHAVIORAL problems
past or present
Dose and frequency
Date begun/
ended
Side-effects
List any supplements you have tried or are
currently administering for any problems.
Dose and frequency
Date begun/
ended
Side-effects
v 1/26/2015
Page 6 of 28
DIET AND FEEDING
What do you feed your cat?
*
Brand
Amount
Where
Time of day
How has your cat’s appetite changed?
 Increased  Decreased  No change. If so, describe.
Who feeds the cat?
Where?
Where does your cat drink?
List your cat’s five favorite treats from the
most to least including any human food treats
your cat likes.
How often do you give treats? For what?
Most
v 1/26/2015
% Protein
(from cat
food label)
Least
Page 7 of 28
ELIMINATION BEHAVIOR
Does your cat use a litter pan?
Does your cat ever eliminate in the house but
outside the litter pan?
Describe your litter pans.
Type
Commercial – size, with removable lip or
“Booda”-type door (cat crawls in hole)?
Found/Devised - dishpan, cardboard box, other
(describe)?
*
 Yes
 Yes
 No
 No
If so, how trained?
If so,  Urinate  Defecate  Both.
#1
#2
#3
#4
#5
Commercial Commercial Commercial Commercial Commercial
Size ______
Size ______
Size ______
Size ______
Size ______
 Lip
 Lip
 Lip
 Lip
 Lip
 Booda
 Booda
 Booda
 Booda
 Booda
Found
Found
Found
Found
Found
Paper box Paper box Paper box Paper box Paper box
Dishpan
Dishpan
Dishpan
Dishpan
Dishpan
 Other:
 Other:
 Other:
 Other:
 Other:
How old?
Liner?
_____Yrs
 Plastic
 Newspaper
 Other:
_____Yrs
 Plastic
 Newspaper
 Other:
_____Yrs
 Plastic
 Newspaper
 Other:
_____Yrs
 Plastic
 Newspaper
 Other:
_____Yrs
 Plastic
 Newspaper
 Other:
Type of litter including brand?
__________
 Clumping
 Clay
 Multi-cat
 Other:
__________
 Clumping
 Clay
 Multi-cat
 Other:
__________
 Clumping
 Clay
 Multi-cat
 Other:
__________
 Clumping
 Clay
 Multi-cat
 Other:
__________
 Clumping
 Clay
 Multi-cat
 Other:
Recently changed brands?
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Yes  No
From?
_________
Why?
_________
 ___x /Day
 ___x /Wk
 ___x /Mo
 Wipe out
 Wash
 Water
 Chem sol
 Water
 Chem sol
 Water
 Chem sol
 Water
 Chem sol
 Water
 Chem sol
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 Yes  No
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 Don’t know
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
 ___x /Day
 ___x /Wk
 ___x /Mo
How often scooped?
How cleaned and how often?
How often is litter replaced?
Does the cat cover urine and feces in the box?
v 1/26/2015
Page 8 of 28
DAILY SCHEDULE
Describe a typical 24-hr day in your cat’s life.
How does your cat behave with familiar
visitors?
With unfamiliar visitors?
Does your cat behave differently with children?
Differently with familiar vs unfamiliar children?
Differently with toddlers and babies?
How do you play with your cat?
What toys does your cat have?
Prefer?
Does your cat go outdoors?
Is your cat supervised outdoors?
Is your cat harness/leash trained?
How much time does your cat spend outdoors
daily?
SOCIAL BEHAVIOR
Specifically where does your cat sleep at night?
Where is his/her favorite sleep spot?
Has your cat’s sleep changed in pattern or
length?
Have you ever used a crate or room to confine
your cat?
Do you still use the crate or room?
Where is your cat when alone in the house?
When you have guests?
How does your cat behave while you are
leaving the house?
When you return?
How does your cat behave with adult visitors?
Children?
How does your cat behave with the
veterinarian?
Does your cat respond to cats seen out of the
window or in the yard?
When does your cat meow?
Hiss or growl?
What is your cat’s activity level in general?
*
 Yes  No If so, how does your cat signal to go out?
 Yes  No
 Yes  No
If so, how trained?
______  Hrs  %
 Yes
 No
If so, describe.
 Yes
 No
If so, describe your cat’s reaction.
 Yes
 No
If so, what for? If not, why?
 Yes
 No
If so, describe.
 Low
 Average
 High
 Excessive
If excessive, describe:
How would you describe your cat’s
personality?
v 1/26/2015
Page 9 of 28
GROOMING
Does your cat groom, lick or bite him/herself
excessively?
Does the cat’s skin ripple?
Is your cat declawed?
If so, what was the aftercare?
Did you use newspaper in the pan?
Did your cat use this litter?
Did the paws become infected after surgery?
Describe your cat’s favorite scratching area or
post?
*
SEXUAL BEHAVIOR
Has your cat ever been bred?
If you have a female, was she a good mother?
If your cat is intact, are you planning to breed?
If your cat is neutered/spayed, at what age?
Were there behavior changes after neutering?
Does your cat mouth other cats, other animals
or people?
*
v 1/26/2015
 Yes
 No
If so, describe.
 Yes
 Yes
 No
 No
If so,  Front only  Both
 Yes
 Yes
 Yes
 No
 No
 No
 Yes
 Yes
 Yes
______
 Yes
 Yes
 No
 No  Unknown If not, describe.
 No  Neutered/spayed
 Months  Yrs
 No  Unknown If so, describe.
 No  Unknown If so, describe.
Page 10 of 28
TRAINING
What training has your cat had?
How old was your cat when training started?
*
 None
 HomeTaught
 Agility
 Flyball
 Private
______ Yrs
What type of training collar was used?
 Started
class
Graduated
Class
Graduated
2+ classes
Other – describe.
Trainer’s
Name
Describe
Response
Grade 1-5
Good-poor
None (off leash)
Neck collar
Remote collar (shock, citronella)
Head halter
Body harness
Who in the family is the primary trainer?
Have you or do you plan to exhibit your cat in
Yes No
If so, describe.
breed shows or cat sports?
Describe any awards or titles your cat has.
What percent of the time does your cat obey the following commands for each member of the family?
Family Member Name
Sit
Down
Stay
Come
Heel
(don’t pull)
Yes No If so, describe.
 Reward Assertive/  Aversive/ Other - describe:
Describe the training you tried with your cat.
based
dominance/
mostly
pack style
corrections
Describe your cat’s reaction to any of the following if you have used for punishment OR training.
 Behavior stopped/diminished  Behavior worsened/intensified
Physical contact
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Noise (shaker can, siren)
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Ultrasonic
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Water sprayer
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Verbal reprimands
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Muzzle grasp
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Pinning/alpha roll
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Time-out
Describe.
 Behavior stopped/diminished  Behavior worsened/intensified
Booby-traps/repellants
Describe.
Will your cat settle or relax on command?
v 1/26/2015
Page 11 of 28
Punishment
Is any punishment effective?
What punishment is most effective?
Are others needed?
Does the behavior decrease in frequency or
intensity over the course you use this
punishment?
Describe any punishment that makes the
problem worse.
Describe any punishment that led to
threatening behavior, aggression or fear.
Does your cat respond differently to
punishment from different family members
v 1/26/2015
 Yes
 No
If so, what?
 Yes
 Yes
 No
 No
If so, what?
If so, describe.
 Yes
 No
If so, describe.
Page 12 of 28
AGGRESSION SCREENING
* Fill out even if aggression is not the main problem.
Not all of these represent appropriate/recommended ways to interact with an animal.
Do NOT try these situations if you don’t already know what might trigger your cat.
Screen can be used in several ways: 1) to note presence/absence of a behavior; 2) as a log noting number of occurrences, times
attempted during a period of time; and/or 3) as a log noting frequencies to compare to #2.
Key: None = no reaction Paw swat Hiss = aggressive hiss Growl = serious, not play Snap = no skin contact
Bite = skin contact Withdraw = cower, avoid N/A = not applicable; never been in that situation
+/- = increasing/decreasing
What is your cat’s response to:
 None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family petting the cat
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family hugging the cat
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family kissing the cat
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family lifting the cat
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family calling off furniture
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family pushing/pulling off furniture
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family approaches on furniture
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family disturbs while resting/sleeping
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family approaches while eating
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family touches while eating
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes cat food away
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes water dish away
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes rawhide
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes biscuit/cookie
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family takes real bone
Frequency:  +/ Intensity:  + / Family approaches when cat has any
 None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
object/toy/bone
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family verbally punishes
Frequency:  +/ Intensity:  + / Family poses visual threat, i.e., stare, wave
 None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
arms at cat
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family speaks to cat in normal tone
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family stares at cat
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family bends over cat
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family pushes on shoulders or back
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite  Withdraw  N/A
Family approaches cat near spouse
Frequency:  +/ Intensity:  + / v 1/26/2015
Page 13 of 28
What is your cat’s response to: (cont)
Family enters room
Family leaves room
Family reaches toward cat
Family uses leash restraint
Family uses collar restraint
Family uses scruff restraint
Family takes leash off/on
Family puts collar on/off
Family bathes cat
Family towels cat
Family grooms/brushes cat
Family trims nails
Family uses leash/collar correction
Family uses “sit”
Family uses “down”
Familiar adult enters house/yard
Familiar child enters house/yard
Response to familiar toddler/child
Familiar adult approaches owner and cat on
leash
Familiar child approaches owner and cat on
leash
Stanger petting the cat
Strange hugging the cat
Stranger kissing the cat
Stranger lifting the cat
Stranger calling off furniture
Stranger pushing/pulling off furniture
Stranger approaches on furniture
Stranger disturbs while resting/sleeping
v 1/26/2015
 None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + / -
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
Page 14 of 28
What is your cat’s response to: (cont)
Stranger approaches while eating
Stranger touches while eating
Strange takes cat food away
Stranger takes water dish away
Stranger takes rawhide
Strange hugging the cat
Stranger kissing the cat
Stranger lifting the cat
Stranger calling off furniture
Stranger pushing/pulling off furniture
Stranger approaches on furniture
Stranger disturbs while resting/sleeping
Stranger approaches while eating
Stranger touches while eating
Stranger takes cat food away
Stranger takes water dish away
Stranger takes rawhide
Stranger takes biscuit/cookie
Stranger takes real bone
Stranger approaches when cat has any
object/toy/bone
Stranger verbally punishes
Stranger poses visual threat, i.e., stare, wave
arms at cat
Stranger speaks to cat in normal tone
Stranger stares at cat
Stranger bends over cat
Stranger pushes on shoulders or back
Stranger approaches cat near spouse
Stranger enters room
v 1/26/2015
 None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + / -
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
Page 15 of 28
What is your cat’s response to: (cont)
Stranger leaves room
Stranger reaches toward cat
Stranger uses leash restraint
Stranger uses collar restraint
Stranger uses scruff restraint
Stranger takes leash off/on
Stranger puts collar on/off
Stranger bathes cat
Stranger towels cat
Stranger grooms/brushes cat
Cat at groomer’s
Stranger trims nails
Stranger uses leash/collar correction
Stranger uses “sit”
Stranger uses “down”
Adult stranger enters house/yard
Child stranger enters house/yard
Response to toddler/child stranger
Stranger adult approaches owner and cat on
leash
Stranger child approaches owner and cat on
leash
Response to strangers when off leash
Cat at veterinary clinic
Cat in car, sees people/animals at tollbooths,
gas stations
Cat in house, sees people/animals outside
Response on leash to other cats
Response off leash to other cats.
v 1/26/2015
 None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + /  None  Swat  Hiss  Growl Snap  Bite
Frequency:  +/ Intensity:  + / -
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
 Withdraw  N/A
Page 16 of 28
Characteristics of Aggressive Episodes
Attacks are sudden and surprising.
Episodes appear unprovoked.
Cat is abruptly docile afterward.
Cat appears “sorry” afterward.
Episodes associated with “glazed” or “absent”
expression.
I can usually tell what will set off my cat.
The behavior is new and uncharacteristic.
Describe a typical aggressive episode, e.g.,
growl, lunge, bite, etc.
What is the usual circumstance?
Given the same situation 10 times, how many
result in aggression?
Has the frequency or intensity of the behavior
changed since the problem started?
Does your cat exhibit periodic diarrhea or
gastrointestinal distress?
Episodes of Human-Directed Aggression
If your cat bit as a kitten, at what age?
Describe the first time your cat growled at a
person. At what age?
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
 Yes
 Yes
 No
 No
0
1
 2-3
 Yes
 No
If so, describe.
 Yes
 No
If so, describe.
0
 Yes
1
 No
2
3
If so, describe:
 4-5
 6-7
 8-9
 >10
4
5
 >5
Describe the first time your cat snapped or bit
at a person. At what age?
If your cat has bitten a human, total number of
bites?
Does your cat bite more than once per
episode?
1
Pre-Bite
(air bite)
Human Bite Levels
2
Near Bite
(tooth
contact, no
puncture)
3
Shallow
Bite
(less than
depth of
canine
tooth)
4
Deep Bite
(depth of
canine
tooth)
5
6
Multiple
LifeBites
threatening
(deep and
(flesh
multiple) consumed
or victim
death)
Number of bites by severity?
Number of bites to part of the body?
Face
Torso
Arms
Legs
Who is/are the targets of aggression?
M/F
Infant/Child/Adult
Dark/Light Skin
Tall/Short
Carrying Box/Cane/Umbrella
Hat/Uniform
How many bites to humans were reported?
To whom were they reported, i.e., local
authorities, hospital, human society?
Was legal action taken?
v 1/26/2015
 Yes
 No
If so, describe:
Page 17 of 28
Episodes of Cat-Directed Aggression
If your cat has bitten another cat, total number
of bites?
Bite Levels
Number of bites by severity?
How many bites to cats were reported?
To whom were they reported, i.e., local
authorities, hospital, human society?
Was legal action taken?
v 1/26/2015
0
1
2
3
4
5
1
2
3
4
Pre-Bite
Near Bite
Shallow
Deep Bite
(air bite)
(tooth
Bite
(depth of
contact, no (less than
canine
puncture)
depth of
tooth)
canine
tooth)
 Yes
 No
 >5
5
6
Multiple
LifeBites
threatening
(deep and
(flesh
multiple) consumed
or victim
death)
If so, describe:
Page 18 of 28
ANXIETY AND FEAR REACTIVITY SCREEN
*
Behavior While Alone or Totally Without the Client
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Inappropriate urination
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Inappropriate defecation
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Vocalization – hissing, screaming, etc.
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Salivation – drooling, slobbering, etc.
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Panting
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
Behavior While VIRTUALLY Alone, i.e., client is home but not accessible, door closed, etc.
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Destructive behavior
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Inappropriate urination
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Inappropriate defecation
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Vocalization – hissing, screaming, etc.
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Salivation – drooling, slobbering, etc.
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
 Always  Frequently  Occasionally  Seldom  Never  Don’t Know
Panting
If so, within  5 min  5-30 min  30-60 min  1-3 hrs  only after 3 hrs
Reactions to Noise
 Salivate  Defecate  Urinate
 Always (>95%)  No reaction
 Escape  Pant
 Pace
 Frequently
 Don’t know
 Hide
 Tremble  Destroy
 Occasionally
Thunderstorms
 Freeze  Won’t eat  Pupils dilate  Rarely
 Vocalize (hiss, whine, growl, howl)
 Never
Destructive behavior
Fireworks
Gunshots/backfires
Mechanics, i.e., vacuums, blowers, etc.
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (hiss, whine, growl, howl)
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (hiss, whine, growl, howl)
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (hiss, whine, growl, howl)
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (hiss, whine, growl, howl)
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
Reactions to Noise (cont)
Siren
v 1/26/2015
Page 19 of 28
Cars
How frequently do noise events occur in the
cat’s environment?
Has this cat ever been treated for noise
sensitivities or phobias?
v 1/26/2015
 Salivate  Defecate  Urinate
 Escape  Pant
 Pace
 Hide
 Tremble  Destroy
 Freeze  Won’t eat  Pupils dilate
 Vocalize (hiss, whine, growl, howl)
 Frequently – multiple times per week
 Regularly – almost weekly
 Occasionally – 2-3 times per month
 Almost never – 2-3 times per year
 Yes  No If so, describe:
 Always (>95%)  No reaction
 Frequently
 Don’t know
 Occasionally
 Rarely
 Never
Page 20 of 28
*
PREVIOUS TREATMENT SCREENING
General Approaches
Kitten socialization class
Private trainer
Agility trainer
Send to a shelter
Place in another home
Euthanize or kill
Consult your vet
Consult a non-veterinary behavior consultant
Consult a veterinary behaviorist (DACVB)
Make into outdoor cat
Specific Approaches
Stare at or “stare down”
Grab by scruff/neck and shake
Get a companion cat for this one
Step on leash or choke collar and force down
Blow in nose or face
Provide different types of cat toys
Fabric choke collar
Metal choke collar
Prong collar
Harness
Martingale collar
Electronic or shock collar by owner
v 1/26/2015
Screen is used to evaluate the role previous treatment recommendations
may play in your cat’s problems or in their resolution – first in a general sense
and secondly for specific actions.
Suggested
By whom
Attempted
Outcome
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
Suggested
By whom
Attempted
Outcome
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
 Yes  No  Friend  Vet
 Yes  No
 Trainer  Other
Page 21 of 28
Specific Approaches (cont)
Electronic or shock collar by trainer
Citronella collar
Citronella spray
Throw a tin or can of pennies
Water pistol
Whistle
Foghorn
Hit cat with hand
Blow torch
Hit cat with empty plastic soda bottle
Hit cat with whiffle ball bat
Hit cat with leash
Hit cat with chain
Hit cat with board, plank or baseball bat
Hit cat under chin
Step on cat’s toes
Knee cat in chest/belly
Kick cat
Bite cat
“Alpha roll” (hold spread-eagle on back)
“Dominance down” (hold down on side, legs
extended, head flat)
Growl at cat
Yell or scream at cat
“Time out” (where, how and for how long)
Praise for good behavior
v 1/26/2015
Suggested
By whom
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
Attempted
 Yes  No
Outcome
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Page 22 of 28
Specific Approaches (cont)
Crate
Kennel outdoors
Fenced yard
Invisible fence
Isolate in house (where and for how long)
Board at vet
Board at kennel
Whip
Chain
Cattle prod
“String up”, hang by leash and collar (all 4 feet
off ground)
Pop and jerk leash
Yank or pull on leash
Tie up physically
Tie out or stake on very short lead hooked to
wall or floor
Muzzle
Increase exercise
Increase play
Give treats for good behavior
Deprive of food
Throw against wall
Beat with your fists
Shove cat’s nose/face into urine, feces or
destruction
Use scat mats or other electronic avoidance
systems
Thundershirt or Anxiety Wrap
Other:
Other:
v 1/26/2015
Suggested
By whom
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
 Yes  No  Friend  Vet
 Trainer  Other
Attempted
 Yes  No
Outcome
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Page 23 of 28
REPETITIVE BEHAVIORS HISTORY
Grooming
Hallucinatory
Consumptive
Locomotory
Vocalization
Patterns of Repetitive Behavior
Was there a change in the household or an
event associated with the development of the
behavior?
Is there any time of day when the behavior
seems more or less intense?
Is there a person or another pet in the
presence of whom the behavior seems more
intense?
Does the cat respond to its name or seem
aware of the surroundings while in the midst of
the behavior?
Is the cat aware that you are calling him/her?
Can you convince the cat to stop the behavior
by calling him or her?
By using physical restraint?
List the kinds of things, i.e., noises, treats, toys,
if any, that will interrupt the behavior once it
has started.
Is there a location in which the cat prefers to
perform the behavior?
For ingestion, list what types of objects are
consumed – as specifically as possible.
Does any event or behavior routinely occur
immediately BEFORE the behavior begins?
Does any event or behavior routinely occur
immediately AFTER the behavior begins?
Has the cat’s general changed in any way since
the onset of the atypical behavior, i.e., the cat
is more or less aloof, aggressive, withdrawn,
playful, etc.?
Has the cat’s diet recently been changed>
How old do you think your pet was when its
ritualistic behavior began?
v 1/26/2015
*
Complete or check only if your cat is showing repetitive or ritualistic
behaviors that you find troublesome or about which you are concerned.
 Chewing self  Biting self  Licking self  Plucking hair
 Barbering/trimming hair on self
 Continuously doing any of these behaviors to another individual
If so, describe:
 Other If so, describe:
 Staring and fixating on things that are not there
 Tracking things that are not there
 Pouncing on or attacking things that are not there
 Other If so, describe:
 Consuming rocks
 Consuming dirt or soil
 Consuming other objects  Licking or gulping air
 Eating, licking, sucking or chewing wool or fabric, rugs, furniture, etc.
 Other If so, describe:
 Circling/spinning  Tail-chasing  Freezing
 Other If so, describe:
 Rhythmic hissing  Howling
 Growling
 Other If so, describe:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail what is going on at that
time of day:
 Yes  No  Uncertain If yes, describe who this is and their association
to the pet?
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
 Yes  No  Uncertain If yes, describe in detail:
_____Yrs
Page 24 of 28
Patterns of Repetitive Behavior (cont)
Did any other cat in the cat’s family exhibit
these or similar behaviors?
 Yes  No  Uncertain If yes, describe in detail:
Is there a pattern to the behavior?
 Yes  No  Uncertain If yes, describe in detail:
Duration: ____Hrs _____Days _____Wks _____Mos
Pattern – after meals, in AM, etc.:
v 1/26/2015
Page 25 of 28
AGE-ASSOCIATED BEHAVIOR SCREEN
Locomotory/Ambulatory
Appetite
Elimination
Visual Acuity
v 1/26/2015
Complete ONLY if you have a cat more than 7 years old.
Check only one –
 No alterations or debilities noted.
 Modest slowness associated with change from youth to adult.
 Moderate slowness associated with geriatric aging.
 Moderate slowness associated with geriatric aging plus alteration or
debility in gait.
 Moderate slowness associated with geriatric aging plus some loss of
function, e.g., cannot climb stairs.
 Severe slowness associated with extreme loss of function, particularly on
slick surfaces and may need to be carried.
 Severe slowness, extreme loss of function and decreased willingness or
interest in locomoting – spends most of the time in bed.
 Paralyzed or refuses to move.
May check more than one –
 No alterations in appetite.
 Change in ability to physically handle food.
 Change in ability to retain food (vomits or regurgitates).
 Change in ability to find food.
 Change in interest in food (may have to do with sense of smell).
 Change in rate of eating.
 Change in completion of eating.
 Change in timing of eating.
 Change in preferred textures.
Check only one in each category.
Changes in frequency and “accidents”
 No change in frequency and no “accidents”.
 Increased frequency, no “accidents”.
 Decreased frequency, no “accidents”.
 Increased frequency with “accidents”.
 Decreased frequency with “accidents”.
 No change in frequency but “accidents”.
Bladder control
 No change in urination control or behavior.
 Leaks urine only when asleep.
 Leaks urine only when awake.
 Leaks urine when awake or asleep.
 Full-stream, uncontrolled urination only when asleep.
 Full-stream, uncontrolled urination only when awake.
 Full-stream, uncontrolled urination when awake or asleep.
 No leakage or uncontrolled urination but in inappropriate or undesirable
location.
Bowel control
 No changes in bowel control.
 Defecates when asleep -  formed  diarrhea  mixed
 Defecates without apparent awareness -  formed  diarrhea  mixed
 Defecates when awake and aware of action but in inappropriate or
undesirable locations -  formed  diarrhea  mixed
Check only one –
 No change in visual acuity detected by behavior – seems to see as well as
ever.
 Some change in acuity not dependent on ambient light conditions.
 Some change in acuity dependent on ambient light conditions.
 Extreme change in acuity not dependent on ambient light conditions.
 Extreme change in acuity dependent on ambient light conditions.
 Blind.
Page 26 of 28
Auditory Acuity
Interactions
Sleep/Wake Cycle
v 1/26/2015
Check only one –
 No apparent change in auditory acuity.
 Some decrease in hearing – not responding to sounds the cat used to
 Extreme decrease in hearing – have to make sure the cat is paying
attention, repeat signals, go get the cat when called.
 Deaf – no response to sounds of any kind.
Check only one in each category –
Play/Toys
 No change in play with toys.
 Slightly decreased interest in toys.
 Slightly decreased ability to play with toys.
 Slightly decreased interest and ability to play with toys.
 Extreme decreased interest in toys.
 Extreme decreased ability to play with toys.
 Extreme decreased interest and ability to play with toys.
Humans
 No change in interaction with people.
 Recognizes people but slightly decreased frequency of interaction.
 Recognizes people but greatly decreased frequency of interaction.
 Withdrawal but recognizes people.
 Does not recognize people.
Other Pets
 No change in interaction with other pets.
 Recognizes other pets but slightly decreased frequency of interaction.
 Recognizes other pets but greatly decreased frequency of interaction.
 Withdrawal but recognizes other pets.
 Does not recognize other pets.
 No other pets or animal companions in house or social environment.
Check only one –
 No changes in sleep pattern.
 Sleeps more during the day.
 Some change – awakens at night and sleeps more during the day.
 Much change – profoundly erratic nocturnal pattern and irregular daytime
pattern.
 Sleeps virtually all day, awake occasionally at night.
 Sleeps almost around the clock.
Page 27 of 28
FAMILIAL BEHAVIOR HISTORY
If a pedigree is available and any familial behavior history is known, mark each family member –
__ - No known behavior information.
KA – Known affected.
KU – Known unaffected.
TA – Tentatively or possibly affected.
TU – Tentatively or possibly unaffected.
AO – Affected with another behavioral problem.
 No pedigree is available for this cat.
Is a pedigree available?
 There is a pedigree available for this cat but it is not attached.
 Pedigree is attached.
Are any family members known?
 Yes  No If yes, describe.
Are any known family members affected?
 Yes  No
Affected relatives do not have to have the
same form of the condition to be considered
affected. In other words, some cats may lick
themselves whereas others chase their tails. If
you know what other affected cats do,
describe.
Which statement most accurately describes your feelings about the problem?
 I am here only out of curiosity. The problem isn’t serious.
 I’d like to change the problem but it’s not serious.
 The problem is serious and I’d like to change it but, if it remains unchanged, that’s all right.
 The problem is very serious and I’d like to change it but, if it remains unchanged, I’ll keep my cat.
 The problem is very serious and I’d like to change it and, it if remains unchanged, I’ll euthanize or give up my cat.
If considering rehoming or euthanasia, have you discussed this within the family? With the place where you obtained your cat?
Is there anything else you think we should know?
COMMENTS
Attachments
Floor plan for each residence.
Primary vet medical record
Primary vet laboratory results esp CBC, UA, chem screen, T4 (if ever done).
v 1/26/2015
Page 28 of 28