Behavioral Medicine Service
NC State Veterinary Health and Wellness Center
1060 William Moore Drive ∙ Raleigh, NC 27607
Phone: 919-513-6999 ∙ Fax: 919-513-6905 www.ncsubehavior.com
∙ ncstatevetbehavior@ncsu.edu
FELINE BEHAVIORAL HISTORY FORM
The information you provide here is very important in the diagnosis and treatment of your cat’s behavior problem. Please fill out this form as completely and accurately as possible.
 Mail, fax, or e-mail this form to the NCSU Behavioral Medicine Service before your appointment.

Please, bring a map of your home and yard to your appointment. Use keys to indicate the location of each of the following: F = Feeding location, P = Play area, SD = Sleeping (day), SN = Sleeping (night), U = Urine housesoiling, BM = Fecal house-soiling. Use 1, 2, 3, etc. to indicate litter box(es) and respective location(s).
 If possible, bring a video recording of your pet exhibiting its behavior problem.
Today’s Date:
PART I. INFORMATION
OWNER INFORMATION
Last Name: First Name: Spouse/Partner:
Street Address: City: State: Zip:
Primary Phone: Home Cell Work
Secondary Phone: Home Cell Work
E-mail address: Fax:
PET INFORMATION
Pet’s Name: Breed: Color: Date of birth: Age: Weight:
Sex: Male (intact)
Age Obtained:
Male (neutered) Female (intact)
Age neutered or spayed: Declawed? Yes
Female (spayed)
No
Where did you obtain this cat?
BREEDER FRIEND PET STORE ANIMAL SHELTER
Behavior problems of parents or littermates, if known:
RESCUE OTHER
VETERINARY INFORMATION
Your primary veterinarian’s name:
Note: After any behavioral consultation, we will send a discharge summary to your veterinarian.
Name of Clinic or Hospital:
Street Address:
City: State:
Office Phone:
Zip:
Fax:
How did you learn of the NCSU Behavioral Medicine Service?
1

PART II. PRINCIPAL BEHAVIORAL COMPLAINT
Summarize the primary behavior problem in one sentence:
How would you describe the severity of this problem? MILD MODERATE SEVERE
What is your primary goal in coming to see the NCSU Behavior Service?
Have you considered euthanasia? YES NO Please comment:
Describe the last two incidents in as much detail as possible.
1.
Date: Incident:
2.
Date: Incident:
FREQUENCY
Please indicate the number of times the problem has occurred in each of the times indicated.
Past Week Past Month Past Year Total Number of Times
No. of Times
PART III. HOUSEHOLD INFORMATION
PERSONS LIVING IN THE HOUSEHOLD
List each person living in the household, including age, sex, hours away from home, and comment on each person’s relationship with your pet.
Name Age Sex Hours Away Relationship with pet
M F
M F
M F
M F
M F
PETS LIVING IN THE HOUSEHOLD
List all other pets in household. Comment on the relationships between the pets.
Name Species Breed Age Sex Weight Relationship with patient pet
PART IV. BACKGROUND INFORMATION
Question Your Response
2

At what age was your pet when the problem began?
Were there changes in the home at that time?
List techniques you have used to address the problem.
Put (+) next to techniques that seem to have helped.
Put (-) next to techniques that made things worse.
Put (0) next to techniques that had no effect.
Have any drugs or remedies been tried for this problem?
Please list.
Put (+) next to techniques that seem to have helped.
Put (-) next to techniques that made things worse.
Put (0) next to techniques that had no effect.
What do you think is the reason for your cat’s problem?
1.
2.
3.
4.
Additional techniques:
1.
2.
3.
4.
Additional:
CORRECTIONS
Indicate any correction techniques you have used and indicate the effects on your cat’s behavior.
Type of Correction
Have you
Tried?
Yes No Time out
Verbal Scolding
Spanking
Noisemaker
Yes No
Yes No
Yes No
Water bottle/sprayer Yes No
Improved the
Problem
No Effect on the
Problem
Lifting by the scruff Yes No
Other (describe) Yes No
Made the Problem
Worse
PART V. HOME ENVIRONMENT
Briefly describe home: House Townhouse Apartment Other Number of floors:
How long have you lived in this location?
Does your cat ever go outside? YES NO If so, when?
DIET
Food/Treat Brand name How often given?
Cat food (canned)
Cat food (dry)
Other food
Treats
Supplement/Vitamin
Desire for this food type mild moderate strong mild moderate strong mild moderate strong mild moderate strong mild moderate strong
PART VI. BEHAVIORAL PROFILE
HANDLING
Check how your cat responds to the following tasks:
3

TASK
Greeting you
Greeting stranger
Petting/stroking
Grooming
Being picked up
Bathing
Trimming nails
NO REACTION AVOIDS RESISTS GROWLS or BITES FAVORS, PURRS COMMENTS
Are you able to medicate your cat yourself? YES NO
What is the best way for you to give your cat medication?
PART VII. AGGRESSION
Are you having a problem with aggression in your cat? YES NO
If you answered NO, please skip this section and proceed to Section VIII.
TARGET: To whom is the aggression directed? PEOPLE OTHER CAT(S) BOTH
RESPONSE
Indicate your cat’s response to the following situations. Check all that have ever applied.
Task
When cat is approached by person
No Response Hisses Meows
When cat is picked up
When cat is petted/groomed
When cat is scolded or spanked
When cat sees other cat in the household
When cat sees other cat that is outside
To restraint (ex: at veterinarian’s)
To painful stimuli (ex: injection by veterinarian)
Other (describe)
Snarls Bites
Has your pet been reported to animal control authorities or a public health department for biting? YES NO
Is your pet currently in 10-day quarantine for biting? YES NO
PART VIII. HOUSE-SOILING
Are you having a house-soiling problem with your cat? YES NO
If you answered NO, please skip this section and proceed to the Section IX.
House-soiling problem related to: URINE FECES BOTH
Have you ever seen your cat spray urine? YES NO UNCERTAIN
How often (per day or per week) do you detect urine or feces outside the litter box?
4

“CULPRIT”:
If you have more than one cat, which of your cats is house-soiling?
How do you know this cat is the “culprit”?
LOCATION:
In what room or rooms does your cat house-soil?
In what room or rooms (to which your cat has access) does house-soiling NEVER occur?
SUBSTRATE:
What is your cat’s favorite “surface” for house-soiling (ex: carpet, throw rugs, bed, laundry, other):
TEMPORAL PATTERN:
What time of day is your cat most likely to house-soil?
LITTER BOX DATA
Litter Box Information
Number of litter boxes in your home
How often are litter boxes scooped out?
Response
What type of litter box or boxes do you use (ex: plain, covered, or electronic)?
What type of litter do you use? Include type (ex: clay, clumping, newspaper) and brand.
Have you tried other litters?
If so, which types and brands?
Do you use a litter box liner?
YES NO
Types/brands tried:
YES NO
Does your cat dig in the litter box before or after eliminating? YES NO
Does your cat bury urine/feces (at least some of the time) after using the litter box? YES NO
IX. MEDICAL HISTORY
Is your pet up to date on routine vaccinations, including rabies? YES NO
MEDICATION
Indicate any medication your cat currently receives:
Name of Medication Dose (mg) or amount How often? Reason Given?
MEDICAL PROBLEMS
Please list any medical problems your pet has had.
Problem Dates if known
YES
YES
YES
On going?
NO
NO
NO
5

Thank you for taking the time to fill out this form.
Revised 4-6-15
YES NO
6