Feline History Form
The information you provide below will be used during your consultation to develop a diagnosis and
plan of treatment. Please fill it out as completely as you can. All information will be held in strict
confidence and will not be released to any third party without your written consent.
Please return at least 2 business days prior to your cat’s appointment by fax, mail or e‐mail to:
Email:
[email protected]
mmmmm
Fax:
(877)
240-4543
Mail:
Beth L. Strickler, MS, DVM
Veterinary Behavior Solutions
169 Townsend Road
Fall Branch, TN 37656
Today’s Date
Your Contact Information
Your name:
Phone numbers:
(home)
(work)
Address:
(cell)
(fax)
E‐mail:
Your Family Veterinarian’s Contact Information
Family Veterinarian:
Hospital Name:
Hospital Address:
Veterinarian’s Phone Number:
Your Cat’s Information
Cat’s name:
Spayed or neutered?

No

Yes
Breed:
Age at which spayed or neutered:
Cat’s Birthdate:
Weight:
Sex:
Male

Female
Color:
Fur length:
Short
Medium

Long
How old was this cat when you acquired him/her?
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Where did you acquire this cat? (i.e., shelter, breeder, friend, etc.)
How long have you owned this cat?
Declawed/tendonectomized? 
No

Yes
At what age?
If yes, were any of these medications given at home after the surgery?

Meloxicam/Metacam Fentanyl patch 
Antibiotics
Have you previously owned cats? 
No Yes
Why was this cat obtained?

Other
Behavior History
What is the main behavioral problem or complaint?
How serious would you rank this behavior?

Very serious

Serious

Not serious
How often does this behavior occur?

Daily

Weekly

Monthly
Please give a detailed description of the most recent incident:
Date of occurrence:
Please give a detailed description of the very first incident you remember:
Date (or approximation) of occurrence:
How old was your cat when he/she first began showing signs of this behavior?
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How long has the behavior been going on? _______Days _______Months _______Years
Have there been changes in frequency or exhibition of the behavior problem?
What steps have been taken to resolve the behavior problem?
What will you do if this behavior cannot be corrected?
Please list any other behavior problems:
What is your goal for this consultation? What would you like to see accomplished?
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Medical History
Please describe any previous or current medical problems of the cat:
Is your cat currently on any medication or special diet? 
No 
Yes
Please list all (include heartworm prevention and flea medications):
Please list all vaccines given within the last year (include dates given):
Your Cat’s Environment
Please describe all the people living in the household now, starting with yourself:
On a scale of 1 to 10, describe the
Hours away from
First Name
Sex
Age
relationship with the cat
home per day
1 = hate 10 = love
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What type of home do you live in? 
One-story 
Two-story

Apartment

Condo
How many square feet of the house does the cat have access to?
Has the household changed since the cat was acquired? 
No 
Yes
If ‘yes’, please describe (such as addition of family member, addition of pet, move, etc.):
How many times have you moved with this cat since acquiring him/her?
Were there previous owners of this cat? 
No Yes
If ‘yes’, how many?
Reason for surrendering cat?
Diet and Feeding
Feeding
Type of food consumed: 
Canned

Moist

Dry
Brand of food?
Supplements/snacks?
Has there been a recent diet change? 
No Yes
If ‘yes’, from what?
When?
When is your cat fed? (please list times)
Where is your cat fed?
Who feeds your cat?
When is your cat offered treats?
Please describe your cat’s appetite:

Normal

Excessive
Water
Where is the water bowl located?
Water intake: 
Normal

Excessive

Poor
Your Cat’s Daily Routine
Sleeping
Where does your cat sleep at night?
How many hours does the cat sleep per day?
Daytime
Where is the cat typically during the day?
Exercise
What type of exercise does your cat engage in?
What types of toys do you provide for your cat? Please be specific:
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
Human food

Poor
What types of activities do you engage in with your cat? Please be specific:
What rewards work best for your cat (check all that apply)?

Food treats 
Attention Petting 
Play 
Toys
Other Animals
List all animals in the household in the order they were acquired, including pets who have died within
the last year:
On a scale of 1 to 10, describe When
Name
Species
Breed Sex
Age
the relationship with the cat obtained
1 = hate 10 = love
Has the cat ever been outside?

No

Yes
Is your cat currently allowed to go outside?

No 
Yes
If yes, is he/she supervised when outdoors?

No

Yes
How does your cat signal to go outside?
Does your cat use a cat door? 
No

Yes
Is your cat harness or leash trained? 
No

Yes
Is there a scratching post available for your cat? 
No

Yes
If yes, what type of post(s)?
Where are they located?
Does the cat use the scratching post? 
No

Yes
If yes, which type of post(s)?
Does the cat scratch on other objects?
No

Yes
If yes, what else?
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Your Cat’s Interaction with People
To whom is the cat most attached?
Does anyone in the household play with your cat?

No

Yes
If yes, whom?
How often do you/household members play with your cat (check one)?

Once a week

Twice a week

Once a day

Twice a day

Three times per day

More than three times per day
What kind of toys do you use to play with your cat?
What kind of games do you play with your cat?
Do you train your cat?
If yes, to do what?

No 
Yes
Does your cat play with any toys by him/herself?

No

Yes
If yes, what kind of toys?
Are all toys available to your cat at all times?

No 
Yes
What is your cat’s favorite toy?
Does your cat come when called? 
No 
Yes
How does your cat react when you come home?
When is your cat most active (check one)?
How does your cat respond to (check all that apply):
No
Avoids Resists
reaction
Baths
Being Picked Up
Nail Trims
Petting
Friends
Children
Strangers
Veterinarian

During the day
Bites/
Growls
Grooming
Do you brush your cat? 
No

Yes
If so, how does your cat respond?
Are there areas on his/her body where your cat licks excessively?
If so, where?
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Purrs

No

During the night
Never
Tried

Yes
Comments
Elimination Behavior
***Please complete the remainder of this form if your cat is eliminating in areas other than the litter
box. Otherwise, you have completed the history form and may send it to Dr. Strickler. Thank you!**
How was your cat introduced to the litter box?
How old was your cat when he/she was litter trained?
Does your cat do any of the following?
Behavior at litter box
Defecation
Digs a hole prior to

No 
Yes
Urination

No 
Yes
Covers afterwards

No

Yes

No

Yes
Paws at box or ground

No

Yes

No

Yes
Stands on edge of box

No

Yes

No

Yes
Shakes paws

No

Yes

No

Yes
Vocalizes during

No

Yes

No

Yes
Prefers to eliminate in 
No
private
Eliminates immediately 
No
after the box is cleaned

Yes

No

Yes

Yes

No

Yes

No

Yes

No

Yes
Jumps or runs out of
box when done
How many litter boxes do you have?
Who cleans the litter box(es)?
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Comments
Please answer the following regarding all litter boxes. Please use the back if necessary to add more
litter boxes:
Box #1
Box # 2
Box # 3
Type of litter box (covered,
uncovered, etc.)
Size of litter box
(please measure in inches)
How old is the litter box?
Location
Type of litter used
(clumping, crystal, etc.)
Brand of litter
Depth of litter
(please measure in inches)
Is a liner used?
Is anything added to the
litter? If so, what?
How often is the box
scooped?
How often is the litter
completely changed?
How often is the litter box
washed?
What products are used to
wash the box?
Located near noisy
appliances? If so, what?
Located near doors
or hallways? If so, where?
Are air vents nearby?
Distance in inches from
box to food and water?
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Box # 4
When did the elimination problem begin?
How old was the cat when the problem first started?
How often does the problem occur? (please choose one)
times per day
times per week
Under what circumstances does the problem occur?
Has there been a change in frequency of the problem?
If yes, please describe:

No
times per month

Yes
Where does your cat inappropriately eliminate?
(List all locations and material that your cat has used for inappropriate elimination):
Does the inappropriate elimination occur in your presence or when you are not home?
What have you already done so far to correct the problem?
(Please be specific about what and when)
What has your family veterinarian recommended to correct the problem and what were the results?
What cleaning products have been used on the urine/feces spots? (specific brand names, please)
Have you disciplined your cat for this problem? 
No
If yes, how?

Yes
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Please describe in as much detail as possible the following:
a) The first incident of your cat eliminating inappropriately:
b) The most recent incident of your cat eliminating inappropriately:
Please draw a map of your household, indicating where the litter boxes are located, where the cat has
sprayed, urinated, defecated, and where food and water are placed.
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