Thank you for choosing the behavior department here at Hickory. We are very excited to meet your pet and help you both on your way to a better relationship. Please fill out the below information about your pet to help us better understand your situation. The form will save automatically to the computer you are currently using so you can come back later to work on it, if needed. If you have any questions give us a call 610.828.3054. Appointments will not be made until the paperwork is fully filled out and submitted.

[]
1 Step 1

Feline Initial Behavior Appointment 

Cat History
Patient's Name
Breed
Date of Birth
Age
Coat Color
Owner's Name
Street Address
City, State, Zip
Primary Phone
Secondary Phone
Emergency Phone
Primary Veterinarian
How did you hear about us?
Household Information
People Living in Household
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
If you have more than 4 people in your household, please enter them here:
0 /
Other People in Regular Contact with Pet (Petsitter, housekeeper, friends, etc.)
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
If you have more than 4 people in regular contact with your pet, please enter them here:
0 /
Other Pets in Household (In order of when they came into household)
Name
Species / Breed
Current Age
Age Obtained
Name
Species / Breed
Current Age
Age Obtained
Name
Species / Breed
Current Age
Age Obtained
Name
Species / Breed
Current Age
Age Obtained
If you have other pets please enter them here:
0 /
Type of House
How long have you lived in this house?
Since adoption, how many houses have you and your cat lived in?
Neighborhood

List any major household changes since acquiring this cat (ie moves, illness/death of pets/people, added new people/pets to household etc.)

Date:
Event
Date:
Event
Date:
Event
Acquisition Information
How long have you owned this cat?
How old was the cat when acquired?
Where did you obtain this cat?
Behaviors of cat's parents/ litter mates (If known):
0 /
Describe previous homes (If known):
0 /
If obtained from a shelter/rescue, describe the information you were given about cats behavior/ experiences before adoption:
0 /
Why did you choose this breed of cat?
Why did you choose this individual cat?
Why did you acquire this cat (check all that apply)?
Neutering Information
Is this cat neutered/ spayed?
If yes, at what age?
Reason for neutering/ spaying?
Current existing behavior problems (list problems that cat had before neuter that you hoped to correct with surgery)
0 /
Did you notice any changes after neutering/spaying?
Please Describe
If not neutered/spayed, reasons for not neutering/spaying:
Medical History
List of major illnesses/ surgeries (please be sure to include dates):more details
0 /

Please list all medications/ treatments your cat is CURRENTLY receiving, including heartworm, flea/ tick preventative/ collars, dietary supplements, herbal/homeopathic treatments:

Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Name of Medication (as listed on bottle)
Dose/ Frequency Givenyour full name
Date Startedyour full name
Daily Activities/ Routine

Meals/ Types of Food

When and where is your cat fed?
Does your cat have food available all day?
Dry (Brand)your full name
% of Dietyour full name
Canned (Brand)your full name
% of Dietyour full name
Rawyour full name
% of Dietyour full name
Other
% of Dietyour full name
If you feed a special diet (hypoallergenic, grain free etc.) why?your full name
Eating Habits (Check all that apply)
List types of treats:your full name
How often does your cat get treats?your full name
When does your cat get treats?your full name
Where does your cat sleep at night?your full name
Where does your cat sleep during the day?your full name
Does your cat go outside?
If yes...
Please describe (ie. only allowed out during day, outside in fenced yard, out on leash etc.):your full name

Play

Does your cat play with toys?
What are your cat's favorite toys?your full name
How often does your cat play with toys?pick one!
How often does your cat play with people?pick one!
How often does your cat play with other animals?pick one!
Litterboxes

Please fill out the following for each litterbox in your household:

Locationyour full name
Type of Boxyour full name
Sizeyour full name
Type of Litteryour full name
Additivesyour full name
Locationyour full name
Type of Boxyour full name
Sizeyour full name
Type of Litteryour full name
Additivesyour full name
Locationyour full name
Type of Boxyour full name
Sizeyour full name
Type of Litteryour full name
Additivesyour full name
Locationyour full name
Type of Boxyour full name
Sizeyour full name
Type of Litteryour full name
Additivesyour full name
Locationyour full name
Type of Boxyour full name
Sizeyour full name
Type of Litteryour full name
Additivesyour full name
How frequently are litter boxes scooped?your full name
How frequently are litter boxes cleaned?your full name
What cleaning products do you use?your full name
If there will be or have been any major changes to the daily routine (ie. vacations, owner who travels for business, etc.) please describe:more details
0 /

Does your cat engage in any of the following behaviors at least once weekly:

Housesoilingpick one!
Excessive vocalizationspick one!
Destructive scratchingpick one!
Self licking/chewingpick one!
Pacing/ repetitive behaviorpick one!
Consumes non-food objectspick one!
Circles/ chases tail/ freezespick one!

How does your cat react to the following:

Unfamiliar people at doorpick one!
Unfamiliar people in homepick one!
Babiespick one!
Childrenpick one!
Other cats in householdpick one!
Other cats (does not live with)pick one!
Dogs in householdpick one!
Other dogs (does not live with)pick one!
Squirrels/ birds/ etc.pick one!
Carrierpick one!
Car ridespick one!
Veterinarian's Officepick one!
Being left alonepick one!
Thunderpick one!
Loud Noisespick one!
Petting (by familiar people)pick one!
Primary Behavior Problem

Please fill out this section in detail, it will allow us to spend more time during the appointment discussing treatments instead of going over your cat's history:

What is the one main behavior problem you wish to address?more details
0 / 70

Describe the very first incident of this problem.

Try to remember the earliest occurrence of the problem, even if it wasn't as serious as it is now. If you noticed any changes in your cat's body language or facial expression before, during or after the incidents please describe.

For example, if your cat is aggressive to people, describe the first time she hissed or growled at someone, not the first bite. Or if your cat has been house soiling, describe the first "accident" you found. If you noticed any changes in your cat's body language or facial expression before, during or after the incidents please describe.

0 /
Date of first incident and cat's age at the time (approximate date/ age is ok.your full name
Describe per instructions above most recent incident:more details
0 /
Date of most recent incident:your full name
Describe per instructions above at least one other incident you feel illistrates the problem behavior (if you would like to describe other incidents, that's great!):more details
0 /
Date of Incident(s)your full name

Frequency of Primary Behavior Problem:

How frequently does this behavior occur?pick one!
Is the frequency...pick one!
What percent of the time that your cat is in a potentially problematic situation does the problem behavior occur?pick one!
What have you tried to do to correct this behavior problem and how did your cat respond?more details
0 /
How serious do you and other members of the household find this problem?more details
0 /
Has anyone suggested that you euthanize or rehome this cat because of this problem (this is not a recommendation; we just want to know what has been suggested)?pick one!
Have you ever considered euthanasia or rehoming your cat because of this problem?pick one!
List other problem behaviors in order of importance to you.more details
0 /
Do we have permission to post pictures on our social media?
Previous
Next