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Feline Behavior History Form

Owner Information

First Name(Required)

Last Name(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Home Phone(Required)

Work Phone(Required)

Cell Phone(Required)

Email(Required)

Patient Information

Name(Required)

Breed(Required)

Date of Birth / Age(Required)

Weight(Required)

Color(Required)

Sex(Required)

Male

Female

Neutered / Spayed?(Required)

Yes

People Living in Household

How many people live in the household?(Required)

1st Household Member

Name(Required)

Age(Required)

Relationship to owner (e.g. spouse, son, daughter, roommate, etc.)(Required)

2nd Household Member

Name(Required)

Age(Required)

Relationship to owner (e.g. spouse, son, daughter, roommate, etc.)(Required)

3rd Household Member

Name(Required)

Age(Required)

Relationship to owner (e.g. spouse, son, daughter, roommate, etc.)(Required)

4th Household Member

Name(Required)

Age(Required)

Relationship to owner (e.g. spouse, son, daughter, roommate, etc.)(Required)

5th Household Member

Name(Required)

Age(Required)

Relationship to owner (e.g. spouse, son, daughter, roommate, etc.)(Required)

Other People in Regular Contact with Pet (e.g. petsitters, housekeepers, friends, etc.):

How many people are in regular contact with your pet?(Required)

1st Other Person in Regular Contact with Pet

Name(Required)

Age(Required)

Relationship (e.g. pet sitters, friend, grandchild, etc.)(Required)

2nd Other Person in Regular Contact with Pet

Name(Required)

Age(Required)

Relationship (e.g. pet sitters, friend, grandchild, etc.)(Required)

3rd Other Person in Regular Contact with Pet

Name(Required)

Age(Required)

Relationship (e.g. pet sitters, friend, grandchild, etc.)(Required)

4th Other Person in Regular Contact with Pet

Name(Required)

Age(Required)

Relationship (e.g. pet sitters, friend, grandchild, etc.)(Required)

5th Other Person in Regular Contact with Pet

Name(Required)

Age(Required)

Relationship (e.g. pet sitters, friend, grandchild, etc.)(Required)

All Pets Currently in Household

How many other pets are currently in the household?(Required)

* Please list the pets in order as they came into the household.

1st Pet in Household

Name(Required)

Breed (e.g. DHS, Burnese)(Required)

Sex(Required)

Male

Female

Spayed / Neutered(Required)

Yes

Age now(Required)

Age when obtained(Required)

2nd Pet in Household

Name(Required)

Breed (e.g. DHS, Burnese)(Required)

Sex(Required)

Male

Female

Spayed / Neutered(Required)

Yes

Age now(Required)

Age when obtained(Required)

3rd Pet in Household

Name(Required)

Breed (e.g. DHS, Burnese)(Required)

Sex(Required)

Male

Female

Spayed / Neutered(Required)

Yes

Age now(Required)

Age when obtained(Required)

4th Pet in Household

Name(Required)

Breed (e.g. DHS, Burnese)(Required)

Sex(Required)

Male

Female

Spayed / Neutered(Required)

Yes

Age now(Required)

Age when obtained(Required)

5th Pet in Household

Name(Required)

Breed (e.g. DHS, Burnese)(Required)

Sex(Required)

Male

Female

Spayed / Neutered(Required)

Yes

Age now(Required)

Age when obtained(Required)

Household Changes

How many major household changes have you had since acquiring this cat?(Required)

* E.g. moves, illness/death of pets/people, adding new people/pets to the household, etc.

1) Date(Required)

1) Event(Required)

2) Date(Required)

2) Event(Required)

3) Date(Required)

3) Event(Required)

4) Date(Required)

4) Event(Required)

Acquisition Information

How old was the cat when acquired?(Required)

Where did you obtain this cat?(Required)

Breeder

Pet store

Private home/previous owner

Shelter/rescue

Other

Please list "Other" where you obtained the cat.(Required)

Behavior of cat’s parents/littermates (if known)

Describe previous home(s) (if known)

Why did you choose this cat?(Required)

Have you had other cats before?(Required)

Yes

How many cats did you grow up with?(Required)

How many cats have you had as an adult?(Required)

Type of Home?(Required)

Apartment

Condo

Private house

Medical History

List any major illnesses/surgeries & include dates(Required)

* Please include the dates

How many medications/treatments is your cat currently receiving including heartworm, flea preventative, dietary supplements, herbal/homeopathic treatments:(Required)