Ellen M. Lindell, V.M.D., D.A.C.V.B Telephone (845) / Fax.(845) P.O. Box 1605, Pleasant Valley, NY
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1 Ellen M. Lindell, V.M.D., D.A.C.V.B Telephone (845) / Fax.(845) P.O. Box 1605, Pleasant Valley, NY emlvmd@earthlink.net BEHAVIOR QUESTIONNAIRE FOR CATS Client Name: Date: Address: Patient: City, Zip: Species: Phone: H: Breed: W: Sex: Color: Age: Weight: Date of birth: (if known) Veterinarian: Clinic: Referred by (if other than veterinarian): Address: Phone: Medical History: Is your cat neutered/spayed? If YES: at what age was the surgery performed? reason for procedure: routine / attempt to modify behavior any behavior changes after procedure? YES /NO Is your cat declawed? YES /NO If YES, age of cat at the time of surgery? Any complications? Do you recall the type of litter used after the procedure? Provide dates for most recent vaccinations, if applicable: Rabies: Feline Leukemia Vaccine: Feline Distemper: Other: List current medications: List conditions for which your cat has been treated, medication prescribed, and approximate dates: Ellen M. Lindell, VMD, 2004 Page 1 of 7
2 Background Information: Date (approximate) you acquired your cat: Cat s age at the time: Where did you get your cat? SPCA / rescue group / pet shop / professional breeder / other Are you his/her first owner? If No, how many previous owners? Do you know why he / she was given up? Which traits describe your cat as a kitten: friendly / outgoing / shy / fearful / aggressive / playful Please indicate the reason you decided to adopt this cat: companionship / show / other Have you owned pets before? How did you select this particular cat over the others? Do you know the status of your cat s littermates? Home Environment: Describe your home as a single family house / duplex / apartment / trailer Have you relocated since you ve owned this cat? If Yes, please list approximate dates: List all members of your household; ages of children; hours per day away from home: Name Age (children) Hours away Please list all household pets in the order acquired: Name Species Breed Sex Age Age Acquired Describe your cat s relationship to the others animals within the household: Ellen M. Lindell, VMD, 2004 Page 2 of 7
3 Management: Section 1: Please describe a typical 24-hour day in the life of your cat: Section 2: What % of the day does your cat spend indoors? % Do you have a fenced yard? YES/NO Does your cat run unsupervised outdoors? Where does your cat sleep at night? Where is your cat s favorite resting spot when you are home? Describe your cat s favorite toys: Describe any interactive games that you play with your cat and note frequency: Does your cat perform any special tricks? Does your cat usually follow you from room to room? Does your cat have free access to the house when you leave? How does your cat behave when you prepare to leave home? no reaction / looks sad / hides / aggressive behavior How does your cat behave when you return home? no reaction / greet / brief excitement / hides Does your cat use a scratching post? If yes, type of post: location: List or describe the types of items that your cat chews or scratches, if applicable: What specific brand and type of food do you feed your cat? How long have you been feeding your cat this diet? Number of meals per day: 1 / 2 / 3 / ad lib Which family members are responsible for feeding? Location of bowl(s): kitchen / laundry / basement / other When does your cat eat table food? special occasions / after you have eaten / while you eat / never Cat s favorite treats: Describe your cat s reaction to thunderstorms: no reaction / hide / follow person Please describe your cat s overall activity level: excessive / high / moderate / low / very low Ellen M. Lindell, VMD, 2004 Page 3 of 7
4 BEHAVIORAL DETAILS: 1. Please describe the main behavior problem or complaint: 2. Describe the first espisode: 3. Describe a typical episode: a. The behavior occurs: times per day / week / month Please answer the following questions for the main problem: When did you first notice the problem? Describe the first incident: Describe the most recent episode (include approximate date): Please describe several representative episodes in detail. Include the posture of the cat (ears up or back? tail up or down? tail wagging or flicking? crouched or upright?). Describe any vocalization by the cat (growl/ hiss?). #1 approx. date #2 approx. date #3 approx. date Has the frequency of the behavior increased / decreased / remained unchanged? Has the intensity of the problem increased / decreased / remained unchanged? When did the problem become a serious concern, and why did you decide to seek the advise of a veterinary behaviorist? Ellen M. Lindell, VMD, 2004 Page 4 of 7
5 Circle any household changes that occurred within 3 months of the onset of the problem. a) status of household pets: additional pet / loss of pet / illness b) status of household people: new member / loss of person / pregnancy / illness c) change of employment status: new location / new schedule d) other changes? What measures have you taken to correct the problem? How do you generally discipline your cat, and how does (s)he respond? Please subjectively rate your perception of the main behavior problem: 1. not serious 2. nuisance but tolerable 3. not tolerable but would keep this cat if behavior persists 4. not tolerable will give away or euthanize cat if behavior persists Please list any additional behavior problems or concerns you experience with your cat: Behavior: Frequency: 1. times per day / week / month 2. times per day / week / month 3. times per day / week / month Aggression Survey: Please answer the following questions if your cat has bitten a person. Indicate the age of your cat and circumstances surrounding the first bite. Age of cat: Number of bites requiring medical attention: Who were the targets of the aggression? Body parts bitten: hands / arms / legs / face / chest / buttocks / other Is the aggression predictable? Do the attacks appear unprovoked? Is the cat docile afterward? Does he appear disoriented afterward? Does he appear sorry afterward? Do you notice a glazed expression during an attack? Ellen M. Lindell, VMD Page 5 of 7
6 Please circle your cat s response to the following: To cats seen outside the window: ignore / hiss / growl / urinate / run away / other To being brushed: purr / growl / hiss / bite / swat / tolerates it / loves it To being petted by family: purr / growl / hiss / bite / swat / tolerates it / loves it To being held in arms or lap: purr / bite / struggle / rest quietly / hiss How does your cat behave toward visitors? familiar visitors: aggressive / friendly / shy / hides unfamiliar visitors: aggressive / friendly / shy / hides children: aggressive / friendly / shy / hides Under what circumstances does your cat meow? Under what circumstances does your cat hiss? Under what circumstances does your cat growl? Does your cat mount people or other animals? What is it like to medicate your cat? easy-pop in the mouth / hide the meds / never tried / NO WAY Aggression Screen 1. Pet cat 2. Lift cat to hold 3. Approach / pet while resting 4. Lift off furniture or counter 5. Approach or touch while eating 6. Take toy or coveted object 7. Approach when cat is near his/her special person 8. Enter or leave room 9. Stare at cat 10. Speak to cat 11. Verbally punish 12. Physically punish 13. Put leash, harness or collar on 14. Trim nails 15. With veterinarian 16. With groomer 17. Unfamiliar visitor enters house 18. Unfamiliar visitor pets cat 19. Familiar visitor enters house 20. Familiar visitor pets cat N/R=NO REACTION N/R Hiss Growl Swat Bite N/A Comments N/A=NOT APPLICABLE Ellen M. Lindell, VMD Page 6 of 7
7 Litter Box Information: How did you litter train your cat? Does your cat urinate outside the litter box: never / rarely / sometimes / often / most of the time (list locations used) Does your cat defecate outside the litter box: never / rarely / sometimes / often / most of the time (list locations used) Please describe the number, type (e.g. hooded, open), and locations of litter boxes in your home: When did you last change to a new litter box, type, or location? What specific brand and type of kitty litter do you use: --when did you last switch brands or types? --what depth of litter do you routinely put into the box? Do you use a liner in the box? Maintenance of boxes: Scoop clumps or feces: 2+ times daily / daily / times per week Dump entire contents of box: daily / weekly / every 2 weeks / other Wash box: daily / weekly / every 2 weeks / other Type of cleaner: Does your cat cover urine and/or feces in the box? Does your cat scratch inside or near the box? ** For cats exhibiting inappropriate elimination or intercat aggression, please supply a sketch of the floor plan of your house. Note windows, doors, and the location of all scratching posts and litter boxes. Please mark any areas of inappropriate elimination with an X. Ellen M. Lindell, VMD Page 7 of 7
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Day Care & Overnight Stay Enrolment Form
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Dog Surrender Profile
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Canine Behavior Questionnaire
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Cat Behaviour Questionnaire
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Cat Surrender Information & Profile
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Sylvan Lake & Area Serenity Pet Shelter Adoption Application Form
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Incoming Dog Profile
Shelter use only Branch location: Collected by: Dog ID: Incoming Dog Profile The following questionnaire provides us with information about how your dog behaved in many different circumstances while he
INCOMING DOG HISTORY SHEET
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CREATURE COMFORT EVALUATION TO QUALIFY FOR PET THERAPY CERTIFICATION
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