Behavior Questionnaire

General Information
Your Name*
Pet's Name*
Address*
Street Address Address Line 2 City State ZIP Code
Home/Cell Phone*
Work Phone
Breed*
Pet's Date of Birth*
MM slash DD slash YYYY
Pet's Age*
Sex*
- Female
- Male
Neutered/Spayed?*
- Yes
- No
Behavior Problem
What is your main behavior problem or complaint?
When did this problem start?
Do you recall anything specific at the onset of the behavior problem? (i.e. moving, birth of a child, houseguests, construction, parties, etc.)
How frequently does the problem (or problems) occur?
Has the problem changed in frequency or intensity?
Elimination Behavior
How many litter boxes do you have?
Describe your cat’s litterbox and the number of litterboxes in the facility.
Where do they eliminate that is NOT in their litterbox?
Where are the litter boxes?
Does your cat dig in the litter before eliminating?
Does your cat cover urine and feces in the litter box?
Home Environment/Social Behavior
List all family members including people, cats and dogs, as well as any other non-caged animal in the home.
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