From which location did you adopt your pet?* Newington, 701 Russell Road Waterford, 169 Old Colchester Road, Quaker Hill Westport, 455 Post Road East Pet Owner's Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Email* Pet Name*Animal IDBreed*Sex*Age*ColorWeight*Animal HospitalVeterinarianAnimal Hospital Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Hospital PhonePlease fill out the following as accurately as possible. This questionnaire is for both dogs and cats so some questions may not apply to your situation. Refrain from labeling your pet's behavior and instead make objective observations. (Example: rather than stating "My dog has separation anxiety," write "My dog chews on furniture when I leave, urinates in the crate and barks for hours." This will help us determine what is going on with your pet. Please be aware that we may ask you to take your pet to see your veterinarian. Many behavior issues are a result of underlying medical conditions and can be remedied with the appropriate treatment.Primary reason you are seeking a behavior consultation.*Your Pet's Medical HistoryIs your pet altered? Yes No If yes, at what age was the surgery performed?If not altered by CHS, what was the reason for the procedure?Have there been any behavior changes since the procedure? If so, please describe.Please provide dates for your pet's most recent vaccinations, if applicable. Vaccinations listed are for either dogs or cats.RabiesDistemper/ParvoLyme DiseaseBordetella PertussisFelv (Feline Leukemia)FIV (Feline AIDS)Check/list current medications? (Check all that apply) Heartworm prevention Flea/tick/mite control Antihistamine Anti-inflammatory Thyroid hormone Antibiotic Other If any medications were checked, please specify type/brand.List any conditions for which your pet has been treated, medication prescribed, and approximate dates.Describe how your pet behaves at the veterinary office and while being examined.Has your pet ever been to the groomer? If so, how does he/she behave?Your Pet's Background InformationDate (approximate) you acquired your pet.Your pet's age at adoption.Do you know why your pet was surrendered to CHS? Please describe.If applicable, what characteristics describe your pet as a puppy/kitten? (Shy, happy, skittish, pushy, etc.)Why did you adopt this pet?What types of pets have you owned in the past?Your Pet's Home EnvironmentCheck which best describes your home. Apartment Condo in multi-unit building Multi-family home Townhouse Single-family home Other Have you relocated since you've owned this pet? Yes No If yes, please list approximate dates and describe your last home. (Apartment, single-family, etc.)List by name all members of your household, their ages and the approximate amount of time they are away from the home each day.List all your household pets in the order they were acquired. Include their name, species, breed, sex, current age and their age when they were acquired.Management and Routine:Please describe a typical 24-hour day in the life of your pet.What percent of the day does your pet spend outdoors?How is your pet contained/supervised outdoors (fenced yard, tie out, leash only, unsupervised, etc.)?Where does your pet sleep at night?What is your pet's favorite resting spot at home?Is your pet allowed on the furniture? Yes No If so, which furniture does he/she have access to? Is access continuous or regulated? (Only when owner is home, allowed on furniture all the time, etc.)Describe your pet's favorite toys.Describe any interactive games you play with your pet and how frequently.Does your pet typically follow you from room to room? Yes No Does your pet have unlimited access to the house when you are not at home? Yes No If no, please describe the type of confinement.How does your pet behave when you prepare to leave?How does your pet behave when you return home?Would you consider your pet destructive? Yes No If yes, please describe.What types of items does your pet chew/scratch?What specific brand and type of food do you feed your pet?How long has your pet been fed this diet?List number of meals per day and amount per feeding.Which family members are responsible for feeding?Where are the bowls located?If you have other pets, where do they eat?Describe any pertinent feeding routine information.Does your pet eat table scraps? Yes No If yes, please describe.What is your pet's favorite treat?Do you ever use feeder/puzzle toys for your pet? Yes No If yes, when and describe.Please describe your pet's overall activity level.Behavioral Details:Describe your pet's reaction to thunderstorms.Describe your pet's reaction to other noises.Describe your pet's reaction to strangers.What type of formal training have you done with your pet?What type of informal training have you done with your pet?What type of collar/harness do you use for your pet?In what situations are these tools used?Is your pet currently involved in any extracurricular activities? (Agility, flyball, freestyle, etc.) Yes No Does your pet attend a daycare/boarding facility or has he/she in the past? Yes No If yes, describe facility (include name and phone number if possible).Why did you decide to have your pet attend this facility?If no longer attending, why did you pull your pet out?Does your pet jump on family members or others without permission? Frequently Sometimes Rarely Never Does your pet bark at family members? Frequently Sometimes Rarely Never Does your pet bark excessively? Frequently Sometimes Rarely Never Please describe.Does your pet groom him/herself excessively? Frequently Sometimes Rarely Never Please describe.Does your pet urinate/defecate in unacceptable locations? Frequently Sometimes Rarely Never Please describe.Please describe the main behavior problem or complaint in detail.Describe a typical episode.When did you first notice the problem?Describe the first incident in detail.Describe the most recent episode including approximate date.Have there been any changes to your household within 3 months of the onset of the problem? Include status of household pets, members of household, change of employment or schedule.Has the frequency or intensity of the problem behavior changed since it started? If so, how and when?What measures have you taken to correct/manage the problem? Be as specific as possible and describe every step you have taken to correct the problem. Please note if these attempts have improved or worsened the behavior.When this behavior problem occurs, what typically happens BEFORE the problem behavior?When this behavior problem occurs, how do you respond? Is your response immediate or delayed?How do you generally discipline your pet?How does he/she respond to this discipline?Please list any other behavioral problems or concerns you experience with your pet. Include the frequency and circumstances of the behavior.Please answer the following questions if your pet has bitten a person.Indicate the age of your pet and circumstances surrounding the first snap or bite.Number of bites requiring medical attention.Who were the targets of the aggression?What body parts were bitten?Is the aggression predictable? Yes No Unsure Do the attacks appear provoked? Yes No Unsure Is your pet docile after the bite? Yes No Unsure Does he/she appear disoriented afterward? Yes No Unsure Does he/she appear apologetic afterward? Yes No Unsure Do you notice a glazed expression during an attack? Yes No Unsure How does your pet behave towards familiar visitors?How does your behave towards unfamiliar visitors?How does your pet behave towards children?Does your dog ever mount people? Yes No Does your dog ever mount other dogs? Yes No Does your dog ever mount furniture? Yes No Please note any other pertinent information you would like to discuss with the behavior technician.Please answer the following questions if your cat is exhibiting inappropriate elimination or urine marking.Please explain when this behavior first occurred.What have you done so far to remedy this problem? Be as specific as possible.Have you spoken with your veterinarian regarding this behavior? Please explainLitter box avoidance is often due to stress in the cat's environment. Listed are examples of household changes that could create stress. (Check all that apply.) New cat in household New dog in household New person in household Recently lost a pet in household Someone recently left household House has undergone renovation You moved to a new home Your cat was previously an outdoor cat Other If you checked other, please describe.Does your cat urinate a small amount often or large amounts all at once? Small amount often Large amounts all at once Please explain.Does your cat urinate on vertical or horizontal surfaces? Vertical Horizontal Does your cat have a history of urinary tract infections (UTI) or urinary crystals? Yes No If yes, has your cat ever been on a special diet for urinary health? Note which diet.How many cats are in your household?How many litter boxes do they have?Are all the boxes covered? Yes No Please explain.Where are the litter boxes located?Is this a high traffic area in your home? Yes No Do you use box liners and are they scented?What type of litter do you use? Explain if it is clumping, scented, etc.How often do you scoop the litter box?How often do you replace the litter?How often do you wash the box itself?Will your cat use a litter box that other cats use? Yes No Please explain.Will your cat immediately use a freshly cleaned litter box? Yes No Unsure Does your cat cover its urine or feces or immediately leave the litter box? Covers urine and feces Immediately leaves litter box After eliminating, does your cat scratch outside of the box or only inside? Scratches outside Only scratches inside What areas (locations and frequency of use) are used for elimination. Please be as specific as possible.Does your cat ever use a shower, bath tub or sink for elimination? Yes No If yes, how frequently and did this start recently?Is your cat allowed on the furniture and/or counter tops? Yes No If no, why is he/she not allowed?Do you have any climbing furniture for your cat in the home? Yes No Please describe.CAPTCHA
