Today's Date:

Owner's Name [*]

Email [*]

Phone [*]

Pet's Name [*]

NUTRITION

What cat food do you give your pet?

Any medications, supplements, vitamins or other items?

PARASITES

What do you use for parasite/flea prevention?

Number of doses over the last 12 months

Does your cat have a Microchip?
NONE SELECTED YES NO I don't know

MEDICAL

Does your cat vomit more than 1 time per week?
NONE SELECTED YES NO

Does your cat have diarrhea more than 1 time per week?
NONE SELECTED YES NO

Is your cat coughing or sneezing?
NONE SELECTED YES NO

Has your cat’s activity level changed?
NONE SELECTED YES NO

Does your cat scratch, lick, or chew?
NONE SELECTED YES NO

Has your cat’s appetite changed in the last year?
NONE SELECTED YES NO

Has your cat’s weight changed in the last year?
NONE SELECTED YES NO

Does your cat drink more than usual?
NONE SELECTED YES NO

Does your cat urinate more than usual?
NONE SELECTED YES NO

Does your cat urinate or defecate outside of the litter box?
NONE SELECTED YES NO

Does your cat have difficulty jumping to a counter/bed or have difficulty rising from a resting position?
NONE SELECTED YES NO

Does your cat’s breath have a bad odor?
NONE SELECTED YES NO

Does your cat have any behavior problems?
NONE SELECTED YES NO

Do you brush your pet’s teeth or give dental chews/food?
NONE SELECTED YES NO

Has your cat ever had a vaccine reaction?
NONE SELECTED YES NO

LIFESTYLE

Are there other animals in house?
NONE SELECTED YES NO

Number of dogs:

Number of Cats:

Other:

Time spent outdoors?:
NONE SELECTED 0-10% 10-20% 20-50% >100%

Any other concerns you may have about your pet?
NONE SELECTED YES NO

Have you boarded your pet for the day or overnight?
NONE SELECTED YES NO

Does your pet travel to any other geographic areas?
NONE SELECTED YES NO

Has your pet ever had a dental cleaning or procedure?
NONE SELECTED YES NO

Any other concerns you may have about your pet?