Step 3 - Feline Behavior Questionnaire

STEP 3 Important: This is an online form. Do NOT hit the back button when completing the questionnaire. Do not attempt to close the questionnaire before finishing or leave the questionnaire unattended for hours or you can lose all of your work.

Feline Behavior Questionnaire - The Cat Behavior Clinic LLC

You can save this link to complete the form at your convenience: http://www.thecatbehaviorclinic.com/feline-behavior-questionnaire.html You can also relocate this form link in your browser history or on our clinic website's sitemap under "Step 3 Feline Behavior History Form". If you're ready to complete the form now, please answer the following questions in the form below. For phone or Skype consultations, we need to receive this completed form at least 24 hours prior to your scheduled consult for evaluation. All information provided in this questionnaire shall be treated confidentially. Please be sure to click the "NEXT" button after completing each page of the questionnaire. A copy will be emailed to you automatically once you submit it. This form generally takes 30 to 60 minutes to complete. PHOTOS: If possible, please email photos of your cat, litter box areas, feeding areas, closeup photo of your cat's stool if defecation outside of the box, and areas where unwanted behavior occurs to: images@thecatbehaviorclinic.com Again, when completing this form, DO NOT hit any back buttons or try and save the form or close it before completed or you will lose all of your work.

Your First and Last Name*
Email Address*
Your Mailing Address*
City*
State*
Zip Code*
PHONE NUMBER(S) FOR DAY OF CONSULTATION*
SKYPE USERNAME IF YOU WOULD LIKE A VIDEO CONSULTATION (ZOOM VIDEO IS ALSO AVAILABLE).*
Name of cat(s) with behavior problem
Sex
Total number of cats in household*
Dates of birth (or ages) of all cats in household*
Approximate weight
Declawed ?
- Yes
- No
Size (small, medium, or large frame)
Breed (domestic shorthair, domestic longhair, Persian mix, etc.)
Color and markings (be specific)

Who is your regular veterinarian?
Dr. Name
Clinic Name
Address
Phone No.

Behavior Issue(s)
What is the one unwanted behavior that you most want to remedy during your consultation? Please describe it in detail.
List any other behavior issues or concerns
When did you first notice the main behavior problem (age of cat) ?
When did it first become a serious concern ?
Describe the chronology of the behavior problem and how it developed over time.
In what circumstances does the cat exhibit the undesirable behavior ?

How frequently does the problem (or problems) occur (how many times daily, weekly or monthly)
A. Problem
Frequency
B. Problem
Frequency
C. Problem
Frequency
Has this problem changed in frequency? If so, please describe.
Has this problem changed in intensity? If so, please describe.
Has this behavior problem changed at all since it started?
Please describe the last 3 behavior issue occurrences. Give detail of WHERE and approximately WHEN they occurred.
Please list all of the locations the unwanted behavior has been displayed and frequency of behavior. (Examples: Urination on couch daily, 3 times a day for 2 weeks. Defecating by front door twice weekly for 6 months. Aggression with other cat on cat tree daily). Please provide as much detail as possible.
1
2
3
4
5
6
7
8
9
10
What have you done so far to try to correct the problem ?
Have you “disciplined” your cat for this problem? If so, describe.

Elimination Behavior and Litter Box
Does your cat use a litter box?
- Yes
- No
Does your cat ever eliminate in the house but outside the litter box?
- Yes
- No
If yes, does your cat
How many litter boxes do you have?
How long have you had this many boxes?
Where are they? Please be specific: which rooms, which floors of the house?
What kind of boxes are they?
- Covered
- Uncovered
- Both
Please give dimensions of each litter box
How old is each box?
Do you use a liner?
- Yes
- No
What kind of litter is used? Please be specific.
Have you recently changed brands?
How often is litter scooped?
How often is litter replaced?
How do you clean the box(es), and how often (what cleaning products)? Please be specific.
Does the cat cover urine and feces in the box?
Has your cat ever had dry stools, constipation issues, loose stools, or urinary health issues?
Cat's Background
How old was the cat when acquired?
How long have you had this cat?

Diet and Feeding of your cat(s)
What do you feed your cat? Please be specific, e.g. brand name(s).
When do you feed your cat?
- On a schedule
- Food out at all times
If a multi-cat household, describe the feeding locations.
Do you feed your cat treats, or any other food other than it’s regular diet? Please describe.
Has your cat's appetite
- Increased?
- Decreased?
- Stayed the same?
What is your cat's relationship to the other animals (e.g. friendly, hostile, fearful)? Please describe.

Your Cat’s Daily Routine
How do you play with your cat?
Does your cat go outdoors?
- Yes
- No
Is your cat supervised when outdoors?
- Yes
- No
Does your cat use a pet door?
- Yes
- No
What percentage of time does your cat spend outdoors or indoors?
Indoors %
Outdoor %

Social Behavior Patterns
Where does your cat sleep at night (please be specific).
Where is your cat when you have guests?
How does your cat behave with adult visitors?
How does your cat behave with visiting children?
How does your cat behave with the veterinarian?
How does your cat respond to cats seen out of the window or in the yard?
How does your cat respond to birds or other animals seen out the window or in the yard?
When does the cat meow?
When does the cat hiss or growl?
What toys does the cat have?
Does your cat carry toys/objects or "mother" other animals?
- Yes
- No
What is your cat's activity level in general (Tick one):
- LOW
- AVERAGE
- HIGH
- EXCESSIVE
How would you describe your cat's personality?
Sexual Behavior
At what age was your cat neutered/spayed?

Grooming (and Declawing info if applicable)
Does your cat bite, lick or groom itself excessively?
- Yes
- No
Does the cat's skin ripple (roll or twitch along the back)?
- Yes
- No
If declawed, in the front only?
Does your cat groom it’s paws?
- Yes
- No
What was the immediate aftercare of the declaw? (e.g. did you shred newspaper into the litter pan?)
Did the paws become infected after the surgery?
- Yes
- No
Does your cat use a scratching post or favorite scratching area? (please describe).

Medical History
When was the last time your cat had a check-up at the vet?
What kind of diagnostic testing was done?
Blood work?
- Yes
- No
Urinalysis?
- Yes
- No
If urinalysis, was the urine also cultured?
Would you consider having your vet temporarily place your cat(s) on either anti-anxiety medication or holistic remedies during the behavior modification if needed?

General
Please mark/highlight the statement that best describes how you feel about your cat’s problem(s).
- I would like to change the problem, but it is not serious.
- The problem is serious and I would like to change it, but if it remains unchanged, I will live with the consequences.
- The problem is very serious and I would like to change it, but if it remains unchanged I will keep my cat.
- The problem is very serious and I would like to change it; if it remains unchanged I will give him/her up.
- The problem is very serious and I will need to have my cat euthanized if the problem remains unchanged.
On a scale of 1-10, how would you rate the severity of the main behavior issue (10 being the most severe)?
Comments please feel free to list them here.

I/We (collectively “I” hereafter of any person present during the consultation) understand that the behavioral recommendations given by Mieshelle Nagelschneider, Dr. Jim Shultz DVM, associates, and The Cat Behavior Clinic LLC (hereafter, collectively “The Cat Behavior Clinic” or “the Clinic”) are in no way a substitute for veterinary care. I understand that the Clinic is not dispensing any medical advice nor offering a medical diagnosis or recommending medications. I also understand that not all behavior problems can be solved, especially long term ones, and in some cases, only an improvement in the behavior may be the best outcome. I understand that my patience in applying the techniques for a period of time can vary depending on my cat’s own uniqueness and environmental circumstances. I understand that following the behavior plan for 4 weeks in no way assures 100% success and that some behavior issues take a longer period of time to eliminate or further decrease. I understand that if my cat(s) do not have a behavior issue, then I will receive behavior information to help promote a behavior problem-free environment for my cat(s) instead of a C.A.T. Plan. I release the Clinic from any and all liability or legal matters including but not limited to, the health and behavior of any of my pets, personal property damage of any kind, or damages or injury to me or other persons or animals belonging to me or others. Any legal action arising out of this agreement shall be lodged exclusively in the courts of Portland, Oregon. Should the Clinic prevail in an action brought by me, I agree to pay its attorneys’ fees and costs. I hereby authorize the Clinic to contact and forward a copy of my cat’s treatment plan to my veterinarian if they decide to unless I notify the Clinic otherwise. I understand that my progress reports and/or pictures of my cats may be used anonymously as testimonials or case study reviews on the Clinic website or other social media unless I notify the Clinic otherwise. I understand that the Clinic provides behavior services and does not practice medicine and therefore does not diagnose physical illnesses or prescribe or recommend medication (unless by Dr. Shultz who would need to see my cat in-person locally) and may only suggest information to be discussed solely with my own veterinarian. I understand there are no refunds or rescheduling for missed appointments or cancelled consultation appointments without 48 hour notice and failure to send in the feline behavior questionnaire at least 24 hours prior to my appointment does not release me from my responsibility in keeping my appointment. I understand that it’s my job to schedule, reschedule, cancel, and get my questionnaire in on time and that the Clinic provides no reminders. CONSULTATION FEE: I understand that I am paying for Mieshelle's expertise and behavior plan given to me over the phone that I am instructed to take notes on, not her time, and that the fee for all consultation programs by phone or video Skype from the Clinic are $450.00 during the 4 week program provides up to 3 to 4 hours of consult time and the urination/defecation consults up to 3 hours of consult time. I understand if there is a study discount during the month that I schedule, the consultation is $325.00 (for urine or defecation consults only). A single behavior consultation lasting 60 to 90 minutes is $250.00. In-person consultations are $1200.00 and are taken on a case by case basis and the Clinic reserves the right to determine if both veterinarian and behaviorist need to present. Flight, travel, and hotel accommodations are covered by the client for the behaviorist if out of state. Unused appointment time can not be used past your 4 week program time or after a single sessions consultation. PET INSURANCE: I understand that it is not the Clinic's responsibility if my pet insurance declines my claim for behavior help with the Clinic and up to me to know what type of services and providers are covered by my pet insurance policy. FUTURE CORRESPONDENCE FEE WITH BEHAVIORIST: I understand that I can send in updates to the Clinic at no charge for up to 4 weeks from date of initial consultation. I can request a a phone follow-up of up to one-hour for $250.00, or up to 30 minutes for $125.00 for the same behavior issue after I use all of my initial consultation time. I understand that Mieshelle or Dr. Shultz CAN NOT ANSWER INDIVIDUAL EMAILS and that I must use the "Progress Report" link provided to me after the consultation to provide weekly updates and that I'm responsible for scheduling my follow-up calls. I understand there are NO REFUNDS FOR UNUSED TIME and that I must use all of my consult time within the 4 consecutive weeks program time (or during a single sessions consult) from the date of my first consultation unless an extension is granted from the Clinic. PRIVACY: I understand that audio or video recordings of consultations are NOT allowed and all information given during consultations are proprietary and not allowed by me on any public format including any and all media-- written or online or of any public nature. Cancellation fee: I understand that should I cancel my behavior consultation appointment after I submit my questionnaire, there is a $45.00 cancellation fee because the behaviorist spends a considerable amount of time preparing the behavior plan. If after reviewing my completed forms the Clinic determines a consultation would not be appropriate for my cat's behavior issue, then a full refund will be given (or at the Clinic's discretion, a free consultation may be given). We require a MINIMUM of 48 hours notice for cancelling or rescheduling your appointment regardless of when you scheduled your appointment. I understand that this Clinic agreement/release form must be signed by me (and others that may be present during the call) in order for the behavior consultation to take place and any behavior supplemental information sent to me. I understand that the Clinic will do its very best to assist me in solving my cat’s behavior issues, but because results cannot be guaranteed and are usually dependent on owner involvement, refunds are not issued. I understand that the Clinic reserves the right to determine which behaviorist I work with for the duration of the consultation program and that veterinarians can only conduct in-person consultations due to veterinary law or they may work remotely with my own veterinarian. I understand that I must take complete and thorough behavior plan notes during the consult and understand that the behavior plan is given verbally over the phone or Skype video with handout reminders and product/behavior supplemental emailed to me after the consultation. If for any reason a video consultation is not possible because of audio or video issues or poor internet connection, a phone call will need to be conducted in place of the video call, or I can reschedule the video call for a later date. I have read, understood, and comply with all of the terms and conditions above.
Signature #1 of person present for consultation who has read, understood, and complied the Clinic release and agreement form (Please type in first and last name)*
Signature #2 of person present for consultation who has read, understood, and complied with the Clinic release and agreement form (Please type in first and last name)
Signature #3 of person present for consultation who has read, understood, and complied with the Clinic release and agreement form (Please type in first and last name)
Signature #4 of person present for consultation who has read, understood, and complied with the Clinic release and agreement form (Please type in first and last name)
Today's Date*

Step 3 - Feline Behavior Questionnaire - Cat Behaviorist

Feline Behavior Questionnaire - The Cat Behavior Clinic LLC

Who is your regular veterinarian?

Behavior Issue(s)

How frequently does the problem (or problems) occur (how many times daily, weekly or monthly)

What have you done so far to try to correct the problem ?

Elimination Behavior and Litter Box

Cat's Background

Diet and Feeding of your cat(s)

Your Cat’s Daily Routine

What percentage of time does your cat spend outdoors or indoors?

Social Behavior Patterns

Sexual Behavior

Grooming (and Declawing info if applicable)

Medical History

What kind of diagnostic testing was done?

General

What People are Saying