Cat Hospital of Chicago Cat Health History Form

Cat Health History

You are an important member of your cat’s healthcare team. Together, we can provide the best healthcare possible for your cat. This allows us to recognize health problems as early as possible. Our Cat Health History form includes the most recent advances in feline healthcare. Thank you for your participation.

PERSONAL INFORMATION
* required

*Owner's First Name:

*Owner's Last Name:

*Email Address:

*Cat's Name:

Reason For Visit/
Primary Concern:

Would you like a demonstration on:

Brushing Teeth
Nail Trimming
Administering Medication
No, thank you

Do you prefer normal lab results (healthy cats only) relayed to you by:

Phone
Fax
Mail
Email
(please indicate number/email/address):

FEEDING HISTORY

Whether your cat is an only cat or there are multiple cats in your home, do you observe your cat while he or she eats, so you can tell if he or she gets her fair share of the food?

Yes
No
Not really

2. What do you currently feed your cat? (Please check all that apply)

Dry
Canned
Treats
People Food

3. Does your cat prefer:

Dry
Canned
Likes both equally

4. If dry food is fed:

a. Is your cat:	Meal Fed Free Fed (dry food always available)
b. How much is fed?	cups/day I really don’t know
c. Is the amount fed:	precisely measured once daily? precisely measured twice daily? guesstimated once daily? guesstimated twice daily? not measured? (dry food always available)
d. Brand/ variety/ flavor of dry food fed:	Brand
	Variety	(e.g., light, senior, etc.)
	Flavor
e. Does your cat eat all of the dry food that is offered?	Yes No

5. If canned food is fed:

a. Is your cat:	Meal Fed Free Fed
b. How much is fed?	ounces/day or cans/day (canned food comes in 3, 5.5-6 and 14 oz. cans)
c. If you have multiple cats, how many total ounces are divided among your cats daily:	ounces number of cats
d. Frequency of feeding:	once daily? twice daily? more than twice daily?
e. Brand(s)/variety(ies) of canned food fed:	(e.g., light, senior, etc.)
f. Flavor(s) of canned food fed:
g. Does your cat eat all the canned food that is offered?	Yes No

6. If treats are fed:

how many/day?
brand(s)?

7. If people food is fed:

what is fed?
how much is fed?

8. Any recent diet changes?

Yes
No
If yes, please explain:

9. Any recent changes in your cat’s food preference?

CURRENT MEDICATION HISTORY

1. Name:
Dose:	Last Given:	Refill Needed:	Yes No
2. Name:
Dose:	Last Given:	Refill Needed:	Yes No
3. Name:
Dose:	Last Given:	Refill Needed:	Yes No
4. Name:
Dose:	Last Given:	Refill Needed:	Yes No
5. Name:
Dose:	Last Given:	Refill Needed:	Yes No

LITTER BOX HISTORY

1. Litter Type:

Clay
Clumping
Other (please spcify)

Scented
Unscented

2. Litter Box Type:

Covered
Uncovered
Both

Liner Used
No Liner Used

3. Number of Litter Boxes

4. Location of Litter Boxes

5. How Often is Litter Scooped

6. How Often is Litter Changed

HOUSEHOLD BACKGROUND

1. Does your cat ever go outside? (Check all that apply)

Not at all
Sneaks outside
Free roams
Enclosed porch, balcony or cat enclosure
Spends some time outside unsupervised in non-enclosed area, but is primarily indoors
Walks on leash/harness or is otherwise outside with supervision

2. Pets in household

Number of cats (including this cat)
Number of dogs

3. Do other pets in the household go outside?

Yes No

4. Does anyone in contact with the cat and/or litter box have immunocompromised health, or are there any pregnant or elderly persons, or young children in the household:

BEHAVIOR/HEALTH CONCERNS

Please check if your cat has any of the following:

Increase in activity level
Decrease in activity level

Change in sleeping habits and sleeping location
(describe change)

Change in attitude or interaction
(describe change)

Increase in appetite
Decrease in appetite

Increase in water consumption
Decrease in water consumption

Weight Gain
Weight Loss

Coughing
Sneezing
Trouble breathing
If so, is this new?

Hair loss
Sores
Lumps
If so, is this new?

Scratching
Licking
Other
(describe change)

Vomiting frequency
Vomiting Food
Vomiting Hairballs
Vomiting Liquid
Has the frequency of the vomiting changed Yes No

Diarrhea
Constipation

Elimination outside of the litter box
How long has this been going on Straining or frequent trips to the litter box
Change in the amount and/or frequency of urine or stool
If yes, indicate change

Bad breath
Difficulty chewing

Trouble walking
Trouble jumping
Less inclined to walk compared to previous behavior
Less inclined to jump compared to previous behavior

Weakness
Lack of coordination
Shaking
Tremors
Wobbly gait
Limping or stiffness after resting

Does not seek attention/petting as he or she usually has in the past

Reaction after vaccines in past years

Other
(please indicate)