North Shore - Behavior Consultation Cat

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PLEASE NOTE WE REQUEST YOU BRING PROOF OF RABIES VACCINATION TO THE APPOINTMENT IF THE MOST CURRENT VACCINE WAS NOT ADMINISTERED AT OUR HOSPITAL.
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Owner Information* This field is required.
First Name
Last Name
Phone
Email
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Pet Information
Pet’s name
Date of birth (if known)
Breed of cat
Color
MALE
FEMALE
Sex
YES
NO
Has your pet been altered?
How long have you owned your pet?
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If yes,
At what age?
Date of alteration
Reason for altering
Any behavioral changes afteralteration?
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If no,Are you planning to breed this cat?
YES
NO
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Has this pet ever been bred?
YES
NO
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If female, did she experience heat cycles before altering?
Age of 1st heat cycle, if applicable
Rate(s) of heat cycle(s)
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How old was your pet when you first acquired it?
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Has this pet had other owners?
If so, how many?
Why was this pet given up?
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How long have you had this pet?
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Where did you get this pet?
Stray/Found
Breeder
SPCA/Shelter Service
Breed Rescue
Pet Store
Friend
Internet/Newspaper Ad (Not from a breeder)
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Why did you get this pet?
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When was your pet last vaccinated for
Distemper Date (if known)
Rabies Date (if known)
Allowed to run free, unsupervised
Fenced/kenneled/run
Leash-walked only
Outside unleashed, but supervised
Indoors only
Outdoors only
Is this pet (please check all that apply)
What percentage of the day does your pet spend outside?
Apartment
Townhouse/Condominium
House with small yard
House with large yard
Farm
Other
What kind of living situation do you have?
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If other, Please Specify
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Feeding
1
2
3
4
5
How many meals is your pet fed daily?
At what times is your pet fed?
0
1
2
3
4
How often is your pet fed treats daily?
0
1
2
3
4
How often is your pet fed snacks from the table (i.e. human food) each day?
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What exactly is your pet fed(include name brands such as Science Diet Hairball Control or Science Diet Kitten)
YES
NO
Does your pet have allergies?
If yes, please list
YES
NO
Does your pet have any pre existing or current medical problems?
If so, what are they?
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No
Yes
Is your pet currently taking any medications to prevent heart worm?
If yes, which brand?
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No
Yes
Is your pet on any other medications?
If Yes, Please list below
YES
NO
Do you have any other pets?
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Name
Breed
Sex
Age obtained
Age Now
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2
3
4
5
1
2
3
4
5
Name
Breed
Sex
Age obtained
Age Now
Name
Breed
Sex
Age obtained
Age Now
Name
Breed
Sex
Age obtained
Age Now
Name
Breed
Sex
Age obtained
Age Now
Name
Breed
Sex
Age obtained
Age Now
1 of 5
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Using numbers, please label which pet was obtained 1st, 2nd, 3rd, etc.
YES
NO
If so, are any of these pets ill?
YES
NO
Has your household changed since acquiring this pet?
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If yes, Please Specify
Death of human in family
Death of pet in family
Divorce
Marriage
Child moved
Baby born
Pet added
Family moved
Family schedule changed (lost or gained jobs)
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Please list all the members currently living in this household.
Name
Age
Sex
Relation
Occupation
1
2
3
4
5
1
2
3
4
5
Name
Age
Sex
Relation
Occupation
Name
Age
Sex
Relation
Occupation
Name
Age
Sex
Relation
Occupation
Name
Age
Sex
Relation
Occupation
Name
Age
Sex
Relation
Occupation
1 of 5
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Please mark with an asterisk (*) any of the above who are coming to the clinic with the pet. If anyone not listed is coming with the pet, who are they (i.e. friend, neighbor)?
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YES
NO
Do you know how many animals were in this pet’s litter?
# of Males
# of Females
Why did you choose this specific animal from the litter?
Yes
No
Have you had this breed before?
Why did you choose this specific breed?
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YES
NO
Have you had pets before?
YES
NO
Have you had dogs before?
YES
NO
Have you had cats before?
In or on your bed
On its own bed in your room
In a crate in another room
On the floor next to your bed
In another room, where it wants
In another room, locked from your room
Where does your pet sleep? (Please check all that apply)
NO
YES
Does your cat have any high perchesin the house?
YES
NO
If yes, do they use it?
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0
1
2
3
4
5
>5
How often do you play with toys or play games with your pet inside the house daily (on average)?
How long does each play bout last on average (in minutes)
0
1
2
3
4
5
>5
How often do you play with toys orplay games with your pet outsidethe house daily (on average)
How long does each play bout laston average (in minutes)
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In detail, describe how you prepare to leave the house when the pet will be left alone. Do you ignore your pet? Do you seek it out and say goodbye? Do you make a fuss over it? Etc.
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What does your pet do as you prepare to leave?
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0
1
2
3
4
5
6
>6
How many litter boxes do you have?
Open
Covered
Square
Rectangular
Large
Small
Deep
Shallow
Liner
No liner
Other (please specify)
Describe the litter boxes (check all that apply and put parentheses around the number of boxes for which the description is true)
If Other, (please specify)
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Clumping/recyclable
Plain clay
Deodorized
Playground sand
Anything you can get with a coupon
Ashes
Potting soil
None (empty box)
Gravel/rock
Sawdust/wood chips
Wheat husk
Recycled, pelleted newspaper
Shredded paper or paper toweling
Other (please specify)
What kind of litter material do you put in the boxes? (Check all that apply)
If Other, (please specify)
Closet
Kitchen
Bathroom
Bedroom
Attic
Entryway
Pantry
Basement
Stairwell
Other (please specify)
Where are the litter boxes? (check all that apply)
If Other, (please specify)
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Feel free to include a diagram of your cat’s litter box locations if you think that will help us understand the situation.
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Max. file size: 10.6MB
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In detail, describe how your cat uses the litter box. For example, does it scratch in the litter box before eliminating? Cover up feces? Scratch outside the box?
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YES
NO
Does your cat use one litter box forurine and another for stool?
YES
NO
Are the front feet declawed?
If yes - Age declawed
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Is there anything else you would like to tell us about your cat’s behavior?
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What is/are the behavioral problem(s) that you wish to address, and how much of a problem do you consider the behavior to be?
Problem
NotSerious
Serious
Very Serious
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2
3
4
1
2
3
4
Problem
NotSerious
Serious
Very Serious
Problem
NotSerious
Serious
Very Serious
Problem
NotSerious
Serious
Very Serious
Problem
NotSerious
Serious
Very Serious
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Why have you kept your pet despite its behavior problem?
YES
NO
Are you concerned that you may have caused this problem?
Why?
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YES
NO
Do you feel guilty about this problem?
Why?
YES
NO
Have you considered finding another home for this pet?
YES
NO
Have you considered euthanasia(putting your pet to sleep)?
YES
NO
Did someone recommend euthanasia before your visit here?
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If you think it would help us understand your pet’s problem, please use the back of this page or attach a map of your house or the relevant areas of your house (i.e. locations of litter boxes, locations of fences, etc.).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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