CONFIDENTIAL PET BEHAVIOR HISTORY QUESTIONNAIRE
(Note: This information is for Call Ms Behaving use only and your private information will not be
given out without your permission except as required to communicate with parties such as your
primary care veterinarian after the appointment)
Pet behavior problems can be difficult and frustrating to correct. The information you
provide is very important for assessing and treating your pet's behavior problems. Please fill
out this form as completely and accurately as possible (“help us help you”). If questions
clearly do not apply (e.g. obedience training for cats) you are welcome to skip the question,
but please answer all those possible, even if you feel it may not be relevant!
Please answer questions in as descriptive detail as possible (word pictures of what is
happening). Also, be sure to get this and the liability waiver back to me by (fax to 760-2951058 or e-mail to francine@callmsbehaving.com) ASAP (at least 48 hrs prior to appointment)
and have the originals available for the consultation. Thank you.
Client Name(s) ________________________________________________________________
Client Address:________________________________________________________________
Phone #s:
Fax:
(H)
(W)
____________________
(C)
E-mail: ____________________________________
Patient (Pet’s) Name: ______________ Species/Breed: __________ Age:____Weight:_____
Sex:
M (Neutered? Y/N)
Length of time owned:
mos./years
F (Spayed? Y/N)
At what age?
Age of pet when acquired:
Family Veterinarian (Veterinarian and Practice name/phone):________________________________
Referred by: __________________________________________________________________
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
FELINE BEHAVIOR HISTORY
(Note: This information is for practice use only and your private information will not be given out
without your permission except as required to communicate with parties such as your referring doctor
after the appointment)
Behavior problems can be difficult, frustrating problems to correct. The information you provide is
very important for diagnosing and treating your pet's behavior problems. Please fill out this form as
completely and accurately as possible (“help us help you”). If questions clearly do not apply (e.g.
obedience training for cats) you are welcome to skip the question, but please answer all those
possible, even if you feel it may not be relevant! Compose answers to assist the clinician in picturing
what is happening (descriptive details). Please be sure to get this and other paperwork (fax to 760-6134128 or e-mail to Francine@callmsbehaving.com ASAP (at least 24 hrs prior to appointment) and
bring the originals with you to consultation. Thank you.
Type and size of residence: ___________________________________________________________
Patient Name: ____________________ Species/Breed: _______________Color:________________
Age: _______________
Declawed? Y/N
Weight: _____________________ Sex : M/F
At what age?________________
Where was pet obtained/adopted? (friend, breeder, pet shop, shelter, other):
Describe previous home/homes if known:
Describe behavior of parents or littermates if known:
Describe your cat’s personality:
Any other pets in home?
Other pets affected: Y/N
List all major surgical or medical problems and approximate dates:
List all medication currently being taken by this pet:
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
______________________________________________________________________________
List the Names, Ages and Gender (and whether neutered/spayed) of the other pets in the household:
Name
Breed
Age
Age
Adopted
Gender
Spayed/ Neutered?
(and at what age)
How do the pets get along with each other?____________________________________________
Does this pet get along with other animals?
If not, please explain:
_
_________________________________________________________________________
_______________________________________________________________________________
What are the names, ages and relationship to owner (e.g. spouse, son, roommate, etc.) of the people
that are in the pet's environment (“family members”)? What are their daily schedules?
______
Describe briefly how your pet gets along with each family member including any problems:
______________________________________________________________________________
When is the pet fed? Morning noon
Diet:
% dry
% canned
% table scraps
night___ other
By whom?
Brand:
Brand:
Supplements:
Describe eating habits (e.g., picky, voracious):
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
List treats:
How often given?
Favorite treat?
What toys does your cat like to play with?
Who plays with your cat?
How often? ____________________________________________________________________
What are your cat’s favored play times?
Does your cat have a play center ? Y/N
________________________
Describe:
____________________________________
List your cat’s top five rewards (play toys, catnip, treats, attention/affection): ________________
______________________________________________________________________________
Is cat allowed outdoors Y/N
If allowed outdoors unsupervised, how often and for how long?
______________________________________________________________________________
Describe where cat stays/sleeps during the day (when owners are home)
__________________
During the day (when owners are not home)___________________________________________
At night:_______________________________________________________________________
Presenting Complaint(s):
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
What is the primary problem?
When did the problem begin?
What age was your pet when this problem started?
How would you describe the severity of this problem? (circle one)
Mild
Moderate
Severe
The main problem occurs (check off answer): always
(check below or %)
1. When the pet is left alone at home:
2. In the presence of the family members:
3. During the night when the family sleeps:
4. Family home but not watching pet:
Frequency of occurrence:
times per day,
usually
rarely
never
times per week,
times per month, ____ times per year.
Has there been a change in the frequency or appearance of the problem?
What has been done so far to correct this problem?
What was the pet's response to the specific intervention(s) above?
List any techniques that have been at all successful:
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
Please describe:
List any techniques that have made the problem worse:
Were there any significant changes in this pet's environment prior to the appearance of this problem
(circle if seen and comment as needed)?
a. moved or redecorated
e. change in family schedule
b. boarded
f. new family member/roommate
c. visitors (human or pet)
g. diet change
d. type of litter changed
h. other (new pet introduced, etc.)
How did these changes affect your pet?
Describe any changes in the pet’s health when the problem first started:
__________________________________________________________________________________
INAPPROPRIATE ELIMINATION PROBLEM
(Please complete this section thoroughly if your cat has an elimination problem)
Does your cat use a litterbox for stools? Y/N/sometimes
For urine? Y/N/sometimes
Does your cat also eliminate outdoors? Y/N
If yes, what percent of defecation is outdoors? ____ %
What percent of urination is outdoors? ____ %
Does your cat dig/bury after eliminating? Y/N
Does your cat housesoil? Y/N
If yes, circle all that apply: a) urine horizontal surfaces
b) urine vertical surfaces
Where is your cat’s preferred elimination location?
How often is the litterbox cleaned/changed?
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
c) stools
Litterbox location(s)
Type of litter
1.
2.
3.
Type of box
1.
2.
3.
Indicate which of the above boxes your cat prefers:
If you have more than one cat, do they have different litterboxes? Y/N
Do the cats use each other’s litter boxes? Y/N
If no, describe where each cat’s box is located:
IMPORTANT!! YOUR CAT’S HOME ENVIRONMENT
Please use a separate piece of paper to draw a simple diagram of each floor of your home to show all
places your cat eliminates:
Use the following keys to indicate the location of each of the following:
Kitty litter: (use numbers 1, 2, 3 to correspond to box locations above)
Feeding location: F Play area: P Scratching post: SP Site of inappropriate scratching: D
Sleeping area (night-time): SN Sleeping spots (daytime): SD
Site of inappropriate elimination/urine: U Site of inappropriate elimination/bowel movements: BM
Does your cat defecate outside the litterbox? Y/N If yes, how often does your cat defecate outside the
litterbox? (circle one)
a) Few times a month b) Few times a week c) Daily d) Multiple times daily
When is the cat most likely to defecate outside the litterbox?
What percentage of stools are outside the litterbox?
Where, other than the litterbox, does your cat defecate? List room(s) and type of surface(s):
Does your cat urinate outside the litterbox? Y/N If yes, is there a preference for urinating on (circle
one)
a) Upright surfaces, e.g., walls b) Horizontal surfaces, e.g., floors c) Both upright and horizontal
How often does your cat urinate outside the litterbox? (circle one)
a) Few times a month b) Few times a week c) Daily d) Multiple times daily
When is your cat most likely to urinate outside the litterbox?
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
What percentage of urination is outside the litterbox?
Where, other than the litterbox, does your cat urinate? List room(s) and type of surface(s):
Have you ever observed the cat soil outside the litterbox?
If yes, what did you do?
Does your cat continue to soil outside the box while you are observing?
Does your cat ever use its litterbox while you are observing?
Can you think of any pattern (seasons, days of the week) to the problem?
Was your pet ever completely ‘litterbox trained’? Y/N If yes, at what age was the cat fully trained?
Were there any changes associated with the litter or litterbox when the problem began?
What do you think caused the problem?
Is there a particular type of litter or surface your cat seems to prefer?
Are there any surfaces where your cat will not soil?
Is there a particular location your cat seems to prefer for elimination?
Is there a room or location in your house where your cat does not soil? Y/N Have you tried other litter
locations? Y/N
If yes, describe locations and cat’s reaction:
Do changes (moving, new furniture, vacations) dramatically affect your cat?
Does any straining or pain accompany urination? Y/N Or defecation? Y/N
Any blood in the urine or stools? Y/N
Is stool consistency normal? Y/N If no, describe:
Any increase in frequency: Urine Y/N Stools Y/N
Describe:
Any increase in drinking? Y/N Is there an increase in appetite? Y/N
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com
How often per day does your cat pass urine?
Stools?
Call Ms Behaving
Phone: 858-248-1410 * Fax: 760-295-1058
francine@CallMsBehaving.com