PERSONAL INFORMATION

*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 laboratory results (healthy cats only) relayed to you by:

*Please indicate phone/fax number or email:

FEEDING HISTORY

1. 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:

5. If canned food is fed:

6. If treats are fed:

7. If people food is fed:

8. Any recent diet changes?

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

CURRENT MEDICATION HISTORY

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

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

LITTER BOX HISTORY

1. Litter Type:

Clay
Clumping
Other
(if other, please specify)

Scented
Unscented

2. Litter Box Type:

Covered
Uncovered
Top Loading
Automatic

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)

Click here to read about Heartworm Disease in Cats. Cats that spend any time outdoors or in screened windows in warmer months are at moderate to high risk.

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 (these may be especially important if they are changes from your cat’s last visit):

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 nature/type/content of vomiting changed?
Yes No No vomiting


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 frequency of urination
Change in frequency of bowel movements
Straining to urinate
Change in amount of urine or stool
if yes to any of the above, indicate the change and the duration of the change


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

Scratching
Licking
Other changes in grooming:

Other
(please indicate)

Are there behaviors you would like help working with?