Cat Hospital of Chicago Pre-Exam Patient Questionnaire

Pre-Exam Patient Questionnaire

You are an important member of your cat’s health care team. Together, we can provide the best health care possible for your cat with the information that you provide by filling out this form. This allows us to recognize health problems as early as possible.

PERSONAL INFORMATION
* required

*Owner's First Name:

*Owner's Last Name:

*Email Address:

*Cat's Name:

Reason For Visit/
Primary Concern:
(550 character limit)

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) Dry Food Isn't Fed
b. How much is fed?	cups/day cups/feeding Other
If you checked ‘other’ above, if the amount fed is a variable amount, if the amount fed is split between multiple types of dry food, or if the total amount fed is divided between multiple cats, please explain:
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) other (describe below)
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 Canned Food Isn't Fed
b. How much is fed?	ounces/day or cans/day other (describe below) (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
Variety	(e.g., light, senior, etc.)
Flavor
f. 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?

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

CURRENT MEDICATION HISTORY

Sample:
Name: methimazole; Strength: 5 mg; Dose: ½ tablet twice daily; Last given: last night

1. Medication Name:				Strength:
Dose:		Last Given:		Refill Needed:	Yes No

2. Medication Name:				Strength:
Dose:		Last Given:		Refill Needed:	Yes No

3. Medication Name:				Strength:
Dose:		Last Given:		Refill Needed:	Yes No

4. Medication Name:				Strength:
Dose:		Last Given:		Refill Needed:	Yes No

5. Medication Name:				Strength:
Dose:		Last Given:		Refill Needed:	Yes No

LITTER BOX HISTORY

1. Litter Type:

Clay
Clumping
Other
(if other, please specify)

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:

Reaction after vaccines in past years

Increase in activity level
Decrease in activity level

Increase in appetite
Decrease in appetite

Increase in water consumption
Decrease in water consumption

Weight Gain
Weight Loss

Bad breath
Difficulty chewing

Diarrhea
Constipation
Straining or frequent trips to the litter box

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

Trouble walking
Less inclined to walk compared to previous behavior
Lack of coordination
Wobbly gait
Weakness
Decreased jumping ability
Shaking
Tremors
Difficulty getting up
Difficulty sitting down
Does not seek attention/petting/combing as
previously did
Moves as though stiff
Does this stiffness resolve with movement
Yes No Don't know

Coughing
Sneezing
Trouble breathing
If so, is this new?

Change in sleeping habits and sleeping location
(describe change)

Change in attitude or interaction
(describe change)

Change in how the cat jumps/climbs
(describe change)

Resents being handled
(is this new)

Elimination outside of the litter box
How long has this been going on

Change in the amount and/or frequency of urine or stool
If yes, indicate change

Hair loss
Hair Clumps
Sores
Lumps
If so, is this new?

Scratching
Licking
Other changes in grooming:

Other
(please indicate)