Cat New Patient Information Packet and Questionnaire

Florida Veterinary Behavior Service Dog Behavior Intake Questionnaire
Lisa Radosta DVM, DACVB
Hello!
Thank you for making a behavioral medicine appointment for your pet. We have been providing specialty behaviorial medicine treatment to our patients in south Florida since 2007. Our team is committed to helping your pet overcome his or her behavior disorders.

In this packet, you will find the following items:

1. A registration form

2. Tips for your pet's appointment

3. A patient questionnaire

These forms will automatically submit to us when you submit online.

Please let us know what we can do to help you in the time leading up to your pet's appointment. You can find maps with our location information and direct numbers to those hospitals at our website:www.flvetbehavior.com.

We are looking forward to meeting you and your pet!

Sincerely,

The Florida Veterinary Behavior Service team
Your Information and Legal Stuff
Primary Owner
(your pet's medical record will be under this person)
Full Name

First NameLast Name
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Secondary Owner
Full Name

First NameLast Name
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Who is your pet's primary care veterinarian? Please list the veterinarian, clinic name and phone.
Please list all veterinary hospitals (including the phone number) where your pet has been seen in the past 5 years.
Who referred you to the Florida Veterinary Behavior Service?
I am the owner(s) of the animal(s) seeking behavioral medicine treatment from the Florida Veterinary Behavior Service. Behavioral treatment, training, and advice when properly maintained after completion can be very helpful in resolving problem behaviors in animals. Because each pet is an individual, no guarantee or assurance can be made as to the results that may be obtained. Animal behavior including aggression is unpredictable and will remain unpredictable after its treatment. Florida Veterinary Behavior Service cannot promise that the animal's Behavior Service treatment, training, or advice will eliminate the animal's potential danger to persons or completely control the animal's aggressiveness. Animals should be closely supervised particularly around children and infants and should be controlled at all times including conformance with local ordinances and "leash laws."I am bringing my pet to this appointment with a full knowledge of these risks and understand and accept the liability that is inherent in owning a pet who has shown aggressive behavior.I understand that all fees are to be paid at the time of service and accept full responsibility for the charges incurred in the treatment of my petTelehealth appointments may be recorded for internal training only.*

I understand
FVBS utilizes ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording. By signing this agreement:1. Appointment Recording: You agree that your pet's appointments may be recorded. 2. UsageRights: You grant us permission to share these recordings, and any other materials you choose to provide, for the purpose of improved clinical documentation.3. Age Confirmation and Understanding: You affirm that you are at least eighteen years old and that you understand and accept the terms of this agreement.*

I understand
We may take pictures and videos as a part of your pet's appointment. Below is a consent form for use for images of your pet. When used, there will not no identifying information of the pet or yourself such as your name. Please consent below to whichever option works best for you.

My pet's pictures and videos are to be used only for my pet's medical record.My pet's pictures and videos can be used for my pet's medical record, textbooks, veterinary publications including journals, textbooks and electronic publications, veterinary presentations.Do not use my pet's picture for any purpose including in his or her medical records.
Primary Owner's Signature (use your cursor to sign)*
Secondary Owner's Signature (use your cursor to sign)
Your Pet's Information
Pet Name
Breed
Date of Birth or Age
Sex

MaleFemale
Neutered/Spayed

YesNo
Age at which your pet was neutered of spayed
Where did you get your cat?
How long have you had your cat?
Has this cat lived with other families?

YesNo
If so, please tell us more about your pet's adoption history.

0/50
Environmental Information
How many people in the household?
Has there been any significant change in your household’s routine or schedule in the past 3 months?

YesNo
If any of those people are at risk of serious illness due to bites, please describe (e.g., children,elderly)

0/50
If you feel that the relationship of the patient with a particular person is important to the assessment and treatment of the problem for which you are bringing your cat, please describe.

0/100
Tell us about your pet's environment. Check all that apply.

Indoors onlyOutdoors onlyIndoor, access to the screened in porch/lanai when let outIndoor/OutdoorIndoor, walked on a leashIndoor, outside with supervisionIndoor, cat door access to the screened in porch/lanai
List the other animals in the household and describe their relationship with the patient.

0/100
If you have multiple pets, please answer the following questions. If not, please skip to the next section Does your pet

sleep with your other catssleep with your doggroom your other catsgroom your dogplay with your other catsplay with your dog
Health, Wellness and Welfare
What is your cat’s activity level in general?

LowAverageHighExcessive
Does your pet take naps during the day when you are home?

YesNo
Does your pet sleep through the night?

YesNo
Have you noticed any change in your pet’s sleeping patterns in the past 3 months?

YesNo

Please fill out the table below.

	Daily	Weekly	Monthly	Several times a year	Never
Vomiting
Diarrhea
Constipation
Decreased appetite

Please describe any significant medical illnesses, treatments and the outcome.
How many play sessions does your cat get per day?
Does your cat have any allergies or food sensitivities?
What do you feed your cat?

Behavior Problem Information

Please fill out the section below regarding your three top concerns about your pet's behavior.
What are your goals for this appointment?

0/100
Problem 1

0/50
Age at which problem 1 started
Please give a description of the significant representative event for this problem.

0/100
Problem 2

0/50
Frequency of problem 2
Please give a description of the significant representative event for this problem.

0/100
Problem 3

0/50
Age at which problem 3 started
Frequency of problem 3
Please give a description of the significant representative event for this problem.

0/100
Rank the problems above in order of importance from most important to least important.

0/100

Florida Veterinary Behavior Service Dog Behavior Intake Questionnaire

Your Information and Legal Stuff

Your Pet's Information

Cancellation Policy