OVRS - Behavior Consent Form

Oakland Veterinary Referral Services 1400 S. Telegraph Rd, Bloomfield Hills, MI 48302 Theresa L. DePorter, DVM, MRCVS, DECAWBM, DACVB Veterinary Behaviorist
Today's Date

MonthDayYear
Date
Date and time of Consultation (if Scheduled)

MonthDayYear
Date
Name

First NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Click here for Canadian Address

Click here for Canadian Address
Address

Street Address

Street Address Line 2

CityProvince

Postal / Zip Code
Home Phone Number
Please enter phone number.
Mobile/Other Phone Number
Please enter phone number.
What is the best means of contacting you?
The Behavior Department will be reaching out by email to schedule your pet's appointment.
Veterinary Clinic
Veterinarian's Name
Clinic Phone Number
Please enter phone number.
Who referred You?
This questionnaire is being completed by:
Have you ever brought in a pet to be seen by ovrs?

YesNo
OVRS department
What was the pet's name, and what last name was it under?

Your Cat’s Early History
Age Obtained:
Date Obtained:
For what reason did you obtain this cat?
Describe your cat’s previous type of home; include where, for how long, with whom, foster home, shelter, whether any interaction with parents or littermates:

The Home Environment: List each family member in the home (Include yourself, children and/ or frequent visitors):

	Name	Occupation	Family Relationship	Sex	Age	Describe how they get along with the cat	Will they be present for the consultation?
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List all other pets in the home:

	Name	Breed	Sex	Neutered/	Spayed?	Age	Describe how they get along with this cat	Will they be present for the consultation?
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Describe your home, neighborhood, and yard:
Please make a large, detailed diagram of your home and email it to the behavior department at behavior@ovrs.com. Label each room; identify windows (W), doors(D), large furniture (e.g., bed, couch, table), litter box locations (LB plus a number for each box), feeding areas (F), and favorite resting areas(R); also indicate where your cat spends the most time. If aggressive encounters are occurring, please indicate (A) where they occur. If your cat is having an elimination problem, please add the locations where your cat eliminates onto the map of your house you made earlier. Label any areas where your cat has urinated or defecated, using these codes: U=Urine, U*=Urine, Most Often, BM=Stool, BM*=Stool, Most Often. Label the type of flooring in each room (e.g., carpet, cement, linoleum, tile).

If you are unable to scan a diagram for attachment to your email, please fax the completed diagram(s) to 248-334-3693 or bring them to your appointment.
Attach diagram here

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Interactive and object/exploratory play
List interactive games/activities/play toys your cat enjoys:
Does the cat have preferred playtimes?
Do you have regularly scheduled sessions of play? If yes, describe how often, when and with whom
Describe your cat’s climbing or hiding tendencies:
Grooming
Does your cat's grooming seem

Less than normalNormalExcessive
When is your cat most likely to groom?
Does your cat lick or groom other cats in the house? If yes, which ones?
Scratching
Is your cat declawed?

Not declawedFront onlyFront and rear
Does your cat's scratching seem to be

Less than normalNormalExcessive
Does your cat have a scratching post? If yes, list how many and describe each
Does your cat scratch any areas or objects other than the scratching post or play areas?
If this is the primary reason for today’s visit, please provide more details in the Primary Behavior Concern section.

	Loves/adores/obsessive/exuberant	Playful	Ambivalent	Dislikes	Unknown	Additional Details
Dry cat food
Dry cat treats
Moist cat treats
Chicken, meat
Canned cat food
Seafood/tuna
Other foods
Catnip
Cat toys
Laser light
Perch tower/high places
Scratching post/pads
Going outdoors
Hunting
Rough-housing
Fetch

	Unknown	Enjoys	Resists	Accepts willingly	Accepts reluctantly	Threatens/aggressive	Cannot attempt
Petting/stroking the head or neck area
Petting/stroking the back or tail area
Belly rubs
Brushing
Being hugged/kissed
Restraint on your lap
Nail trimming
Ear handling/cleaning
Eye cleaning or medicating
Bathing
Tooth brushing
Being lifted/carried
Getting medication

Cat Infomation

	Does not occur	Does occur but not a concern	Does occur, would like to improve	Describe
Jumps on counters
Gets on furniture when not allowed
Goes in rooms where not permitted
Nips/grabs with mouth - "play" bites
Scratches people accidentally or intentionally
Destructive chewing
Destructive scratching of objects and surfaces
Stubborn - listens only when feels like it
Hunting/predation

	Many times per day	Daily	Weekly	Every 2 weeks	Monthly	Never	Other interval	Describe
Cat urinates in litter box
Cat urinates outside litter box
Cat defecates in litter box
Cat defecates outside litter box
Cat goes outdoors
Cat defecates outdoors
Litter box is scooped out
Litter box is completely replaced with new litter
Booby traps/repellents
Litter box is completely cleaned, washed, and dried

	Yes	No	Describe abnormalities or concerns
Litter with deodorizers
Different depths of litter
Other types of litter boxes (i.e. covered, uncovered, lined, unlined, self-cleaning)

	No response	Shyness or timidity (non-aggressive) e.g., ears back, cowering, tail tucked, retreating, hiding	Hissing, growling, threatening but no attack	Bites or attacks but withdraws or ceases when threat is removed	Bites or attacks, chases viciously	Describe your cat’s reaction or level of arousal in these situations
Car rides
Thunderstorms
Noises outside the house (e.g. fireworks)
Noises inside the home (e.g., smoke alarms)
Veterinary visits
Grooming, professional
Grooming, home care
Nail trim
Change in routine
Visitors - friends, familiar people
Visitors - unfamiliar people
Party or celebration
Argument or heated discussion
Animal visitors - familiar
Animal visitors - unfamiliar or stray animals
Yard work (e.g., tree trimming, mowing)
Workers, repair people or craftsmen in home
Remodelling/construction
Power outage
Housecleaning or carpet cleaning

	Litter box location (mark LB number on house diagram)	Type of litter	Type of box (e.g. covered or uncovered, lined or unlined, self-cleaning, other)
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