Pet's Name:	
Last Name:	
Date:
	
Primary Concern
What is the most significant behaviour you want to change? (eg, housesoiling, aggression, howling)
Do you consider this problem currently:  - Mild     - Moderate     - Severe     - Considering euthanasia
When did the behaviour begin? 
What age was your pet?
Did your cat experience any health issues at the time this began?  What were they?
Have you discussed the problem with your vet?  Have medical / physiological / health reasons been ruled out?  Please explain in full.
Were there any changes in the home at or around the time this began?  Any major incidents?
Describe the problem, as of the past week or most recent incident:
Describe the problem's beginning or first incident:
How often does this occur?
Is there anything that appears to trigger it?
Has it been growing more severe or more frequent?  Is there anything that appears to make it worse?
Have any other cats in the home shown similar or other changes in behaviour?
What do you believe caused this to begin?
What has been tried so far to correct this?  (eg, behavioural, punishment, medication)
Has anything been successful at all?  What, and to what degree?
Has anything made this problem worse?  What, and to what degree?
What would you consider to be an ideal result of treatment?
What would you consider an acceptable result of treatment?
How do you feel about this problem?  (eg, angry, worried, disgusted, frustrated)
Is there anything else you want to add, related to this issue?