Date of 1st
consultation: ......../......../........
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Veterinarian's stamp
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Owner's name:
Cat's name:
|
(
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Sex:
M
Spayed
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Reason for the consultation (RC):
...............................................................................
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Has the cat been given medication
the past
12 months:
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||||
Name of the drug
-
-
-
-
|
Dose mg/kg/d
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Start date *
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End date *
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If unknown, treatment duration
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The cat's environment
|
Does the cat live:
in a flat
in a house
(if the cat lives in a house):
does he/she go outside?
yes
no
Other cats and animals:
The cat lives alone
the
cat lives with......... other cats
the
cat lives with........... dogs
The cat lives with
..............................................
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Case
history
|
When did the problems start:
Can the owner identify anything
that started off these problems?
|
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Have further examinations already
been conducted on the cat (to investigate an organic cause)?
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Type
|
Results
|
-
-
-
-
|
-
-
-
-
|
Principal behavioural and physical signs on D0 (please put a cross on
the signs presented by the cat)
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BEHAVIOUR
|
Feeding
o
normal appetite
o
extremely capricious
o
hyperphagia
o
dysorexia
o
hyporexia-anorexia
____________________________________
Drinking
o
normal drinking
o
drinks little
o
drinks little and often
(documented
= no organic cause)
_____________________________________
Auto-stimulatory
o
normal toilet-related
behaviour
o
degraded toilet-related
behaviour
o
licking, nibbling
o
onychophagia (substitutive
o
stereotyped licking/nibbling
activity)
(this
behaviour only stopped by the intervention of another party)
______________________________________
Sleeping
o
normal (or no change)
o
hypersomnia (over 18 h?)
o
hyposomnia (less than 10 h)
o
wakes up in the night
o
insomnia
______________________________________
Exploratory
and territorial
o
normal
o
diminished
o
significant reduction in the
cat's
territorial zone
o
total indifference
o
watchful-hypervigilant
o
avoidance, frequently flees
lack of initiative
o
increased (continuous
o
obsessions (territorial
invasion, particularly of a fellow cat)
exploration - motion)
______________________________________
Eliminatory behaviour
o
normal
o
urinates out of the litterbox
o
defecates out of the litter box
if any sign please precise :
o
systematically
frequency
/week : ..............................................
______________________________________
Marking
Facial
marking and/or allomarking
o
normal
o
increased
o
diminished
o
absent
Urinary marking
o
complete sequence
o
instrumental/stereotyped (and
very frequent)
(=disappearance
of the Flehmen phase)
______________________________________
Aggression
o
no aggression sequence
o
fear-related aggression
o
predatory aggression
o
irritability
(when
the cat cannot flee)
(on small animals,
(triggered by frustration, pain
owner's
legs, etc.)
restraint, handling
o
bites when stroked (the aggression sequences only occur when the cat
is petted)
o
territorial aggression (problems related to living with other cats or
animals)
o
other type (give
................................................................................
______________________________________
Physical
examination
o
normal
o
tachycardia
o
bradycardia (pulse rate:
...-N=160-240)
o
diarrhoea, frequent colitis
o
frequent vomiting
o
ptyalism
(intermittent or chronic)
(> 1/week)
o
acral lick granuloma
o
alopecia in specific areas
o
extensive alopecia
(fur
growing back)
(fur
growing back)
o
alopecia in specific areas
o
extensive alopecia
o
obesity
(fur not growing back)
(fur not growing
back)
______________________________________
Self-control
- mood regulation
o
stays excited (>15') after
o
no self-control
o
hyperactivity
the stimulus has
disappeared
(scratches,
bites when playing)
o
stereotyped vocalisation
o
turns on itself or tail
chasing
o
other type of stereotypy :
o
pacing
o
rolling skin
.........................................................
|
_______________________________________
Attachment/interaction
with owners
o
normal (no change in
o
detachment - avoids
o
will not be held on knees or
in arms
interactions with its
its owners
owners
o
hyperattachment
_________________________________________
Other signs not mentioned
above or any precision you would like to add :
--------------------------------------------------------------------------------
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If the symptoms appear in a specific
chronological order, can you list this order:
¶
...................................
·
...................................
¸
...................................
¹
...................................
º
...................................
The cat's previous development, if known:
(how it was raised, age when separated from its
mother, age when adopted, etc.)
DIAGNOSIS (if possible)
:
.............
TREATMENT
(D0)
Behavioural modification associated
:
yes
no
Regardless of when the behavioural
modification was started or modified, please describe it in a few lines:
...............................
...............................
...............................
...............................
...............................
...............................
...............................
...............................
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