Call:
(252) 702-8299
| Text:
(252) 429-5487
michelle@islandpetvethospital.com
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Feline Training Questionnaire
APPOINTMENT
3
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Today's Date:
*
Owner's Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Phone
*
Email
*
Cat's Name
*
Breed
Color
Weight
Sex
Select Species
Female
Male
Spayed / Neutered?
Yes
No
Age of Cat Now
Age of Neutering
Reason for Neutering
Any behavioral changes following neutering?
Has the cat been declawed?
Yes
No
If so, at what age?
Any behavioral changes following declawing?
Name of Veterinarian and Veterinary Hospital
Date of last physical examination?
Any medical issues?
Please list all current medications & supplements (please include the dose)
Please list any previous behavior medications that have been tried (please include the dose and dates medication(s) were started and stopped)
Presenting Complaint
Please describe your cat's problem(s)
At what age did the problem start, if known?
How long does each incident last, if known?
How often does it occur?
Have there been any changes in the pattern, frequency, intensity and/or length of incidents from the time of onset to the present?
Are there any specific conditions which seem to trigger the behavior?
Can your cat be verbally or physically interrupted when engaged in the problem behavior?
How long is the interval between the behavior stopping and the beginning of the next occurrence?
Describe any methods used to stop the behavior and the cat's response to these methods:
Please give a detailed description of the last 2 times this problem occurred:
Cat's History
Where did you get your cat?
At what age was your cat acquired?
Do you know if your cat's parents or siblings engaged in similar behaviors or any other abnormal behaviors?
How would you describe your cat's temperament? (please check all that apply)
Calm
Hyperactive
Timid
Shy
Aloof
Affectionate
Other
If other, please describe.
List people living in the house with the pet. Please include children's ages:
List other animals in the household, their species, breed, age, sex and whether or not they are neutered. Please note which of these animals were living in the house when this cat was acquired.
Describe interactions between animals in the household:
Do the animals eat together?
Describe interactions between cat and family members:
Has any human or pet to whom the cat was bonded left the home?
Did this coincide with the onset of any of the problem behavior(s)?
Did any of the problem behavior(s) coincide with the addition of a new animal or human to the household?
How does the cat react to other cats outside the house? 1. When the cat is indoors and sees other cats through the window:
How does the cat react to other cats outside the house? 2. When the cat is also outside:
Behavior of cat with strangers in the home:
Behavior of cat in veterinary office and during examination:
Daily Activities
Please describe a typical 24 hour day in your cat's life:
Diet
Type of food given
Frequency of feeding
Other food/treats/table scraps
Does the cat hunt?
If yes, does the cat eat the animals it catches?
Litterboxes
Number of litterboxes in the house
Location of litterboxes
Type of litterbox (check all that apply)
Open
Closed
Large
Small
Type of litter used
Have you used different types of litter in the past?
If so, did changing type affect the cat's behavior?
If the cat's behavioral problem involves inappropriate urination or defecation, is there one particular location or type of surface or material where your cat commonly eliminates? (other than its litterbox)
Have you ever noticed your cat straining to urinate or defecate?
Have you ever noticed your cat straining to urinate or defecate?
Frequency of cleaning of litterbox
Behaviors your cat exhibits during thunderstorms, noise, fireworks, etc
Destructiveness
1 small items (e.g. pens, paper, etc)
2
3
4
5 extensive damage (e.g. holes in wall, etc)
Elimation (Urination, Defecation, both)
1 small amount
2
3
4
5 extensive amount
Salivation
1 damp around mouth
2
3
4
5 wet around mouth and forepaws
Vocalizations (crying, meowing, other)
1 (less than 2 minutes)
2 (5-15 minutes)
3 (15-30 minutes)
4 (30 minutes-1 hour)
5 (more than 1 hour)
If other vocalizations, please describe
Hiding?
1 small amount
2
3
4
5 extensive amount
Where do they hide?
Pacing?
1 small amount
2
3
4
5 extensive amount
Remains near owner?
1 small amount
2
3
4
5 extensive amount
Self damaging behavior?
1 small amount (e.g. licking feet, etc)
2
3
4
5 extensive trauma (e.g. broken teeth, nail, etc)
Trembling?
1 small amount
2
3
4
5 extensive amount
Other? (describe below)
1 small amount
2
3
4
5 extensive amount
Please describe.
Please have your veterinarian send us your pet's medical record including lab work. Documents can be sent by email to michelle@islandpetvethospital.com or by fax to 252-631-0383.
Check in for stressed patients: If your pet becomes excessively stressed at the vet's office and you would like to check in from the car, please call 252-702-8299 as soon as you arrive for your pet's consultation. One of our front desk staff will take your information and let us know you have arrived and where to find you. We will then escort you to our separate entrance so you can avoid the waiting room.
If you provide a video or pictures of your pet(s), would you give us permission to use them for teaching purposes?
Yes
No
Phone
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