Feline History Form Feline Behavior History Form Please complete this form in as much detail as possible and submit at least 1 - 2 days prior to appointment. If you have any questions, call Dr Terry Curtis at 352-294-4397. Thank you; we look forward to working with you and your pet! Step 1 of 2 50% Your Name:AddressStreet AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryEmailPhonePet's NameBreed:Date of Birth/AgeAltered Satus:MaleFemaleNeuteredSpayedIf altered, at what age?Veterinarian's NameStreet AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryVeterinarian's Email or Fax:Veterinarian's PhoneHas the cat been declawed/tendonectomized?YesNoHow did you hear about Dr. Curtis?What prompted you to contact Dr. Curtis at this time?Background InformationMedical HistoryHas your cat had any significant medical problems? If so, list here:Why was the cat obtained?Age cat obtained?Source where cat was obtained:Have you previously owned cats?Did this cat have any previous owners?If Yes, how many owners?How long was the cat owned by each owner?What rewards work best for your cat?Why was the cat given up?Who is the primary caregiver?Diet and FeedingWhat is the cat fed?When and where is the cat fed (ad lib or scheduled meals)? Where is the water bowl located?Does your cat have a good appetite? Is the cat offered any treats?Has there been a recent diet change?Animal’s Environment What type of house do you live in?How many square feet does the cat have access to?Have you moved since the cat was acquired?Please list below each person living in householdEnter name, sex, adult or child, relationship with cat, and hours away from house daily.Please list all the animals in the household:Name, sex, species, breed, age, relationship with cat, when obtained.Is your cat currently allowed to go outside? Is he/she supervised when outdoors?How does your cat signal to go outside? Does it have a pet door?Is your cat harness/leash trained?Is there a scratching post available for the cat?If yes, what type of posts and where are they located?Does the cat use the scratching post?yesnoDoes the cat scratch on anything other than its post? If yes, what else?Where does the cat spend most of its time during the day?Where does the cat sleep at night? Does it sleep through the night?Social BehaviorWho is the cat most attached to?What activities do they engage in often?Does the owner play with the cat? How frequently? What kind of games?Does the cat play with any toys? What kind of toys?How does the cat react when called?Does it come to the caller? YesNo ReactionAvoidsHow does the cat react when the owner comes home?How does your cat respond to bathing?No ReactionAvoidsResistsGrowls/BitesPurrsHow does your cat respond to being picked up?No ReactionAvoidsResistsGrowls/BitesPurrsHow does your cat respond to being greeted by owner?No ReactionAvoidsResistsGrowls/BitesPurrsHow does your cat respond to nails being trimmed?No ReactionAvoidsResistsGrowls/BitesPurrsHow does your cat respond to being stroled or petted?No ReactionAvoidsResistsGrowls/BitesPurrsHow does your cat respond to your friends?No ReactionAvoidsResistsGrowls/BitesPurrsHow does your cat respond to children?No ReactionAvoidsResistsGrowls/BitesPurrsHow does your cat respond to strangers?No ReactionAvoidsResistsGrowls/BitesPurrsHow does your cat respond to the veterinarian?No ReactionAvoidsResistsGrowls/BitesPurrsSexual BehaviorIf female, has the cat ever been in heat?YesNoDoes the cat mount cats, other animals, people or objects?YesNoHas the animal been bred or used for breeding?YesNoGroomingDo you groom your cat?YesNoIf so, how does the cat respond?Does the cat keep its coat in good condition?Are there any areas where the cat licks excessively?Elimination BehaviorHas the cat ever eliminated outside of the litterbox?Method of litter training. How was the cat introduced to the litter box?Age when litter trained: Litter Box InformationPlease answer the question for each litterbox available.Who cleans the litter box?Type of litterbox(s)How old is the box(s)Brand of litter -specify if scented or unscentedDepth of litterIs a liner used? Scented/unscented?Is there anything added to the litter?How often is it scooped out?How often is litter completely changed?How often is litter box washed?What products are used to wash box?Located near noisy appliances?Located near doors or hallways?Are air vents nearby? Distance? Distance of box to food & water?Behavior at LitterboxDigs hole prior to..Defecation -yesDefecation -noUrination-yesUrination-noCovers afterward..Defecation-yesDefecation-noUrination-yesUrination-noPaw at box or ground..Defecation-yesDefecation-noUrination-yesUrination-noStand on edge of box..Defecation-yesDefecation-noUrination-yesUrination-noShake Paws..Defecation-yesDefecation-noUrination-yesUrination-noVocalize during...Defecation-yesDefecation-noUrination-yesUrination-noPrefers to eliminate in private..Defecation-yesDefecation-noUrination-yesUrination-noEliminates just after the box is cleaned...Defecation-yesDefecation-noUrination-yesUrination-noJump/run out of box when done..Defecation-yesDefecation-noUrination-yesUrination-noLitterbox additional comments:Elimination Behavior ProblemWhen did the problem begin?How old was the cat when the problem first started?How often and under what circumstances does the problem occur?Is it urination, defection or both?UrinationDefectionBothHas there been a change in frequency?YesNoWhere does it occur? List location and material(s) eliminated upon.Does the problem behavior occur in your presence or when you are not at home?What has been done so far to correct the problem by the owner or Veterinarian?Does your cat stand or squat during elimination (urination)?Amount of urine produced:Small amountLarge amountIs the urine deposited on a ..verticle surface, like a wallhorizonatal surface, like floor or carpetDo you discipline the cat for this problem? Explain.Describe first incident:Describe most recent incident:Describe second most recent incident:Destructive BehaviorDoes the cat tear up or destroy an objects in the house?YesNoIf yes, what items are destroyed?How often does the problem occur?Has there been a change in frequency?Where does it occur?Does this behavior occur in your presence or when you are not at home?What has been done to correct the problem by the owner or veterinarian?Describe first incident:Describe most recent incident:Describe second most recent incident:“Compulsive Behavior”Does your cat lick itself excessively?If so, describe...Location on body/Frequency - how often/duration-how long.When did the problem begin?Has the problem gotten ..BetterWorseStayed the sameDoes the problem seem to “come and go” at different times of the year?Has your cat ever been worked up for allergies?YesNoDon't knowDoes your cat engage in this behavior when you’re not around? (i.e. you come home to wet fur, etc.)YesNoHas the licking ever caused you to seek veterinary care for ulcerations, infections, etc.?YesNoIf so, what treatment was given/prescribed?Did your cat respond to this treatment? If so, describe.Does your cat chew or suck on fabric of any kind? If so, describe.When did this behavior begin?Has the behavior gotten ..BetterWorseStayed the sameWhat do you do when your cat engages in this behavior?Does your cat engage in this behavior when you’re not around? (i.e. you come home to wet, chewed fabrics)Does your cat engage in any other “strange or unusual” behaviors? If so, describe.Does your cat have any other behavior problems? If so, describe.