Feline Patient History Form

Date

Name*

First Last

Your Pet's Name*

Phone*

Is your address, email, phone number still correct?*

Yes
No

If first visit, is this your first pet?

Yes
No

Do you have other pets you would like entered into our system for compliance & ER situations?

Yes
No

Chief Complaint/Reason for Visit*

Has your pet been seen for the same condition before?

Yes
No

If yes, When?

Any injury or illness in last 30 days?

Yes
No

If yes, Describe

Vaccines Up-to-date?*

Yes
No
I don't know

If yes, please provide date

Has pet had any wellness blood work done?

Yes
No

If yes, when? Provide date if possible

Is pet spayed or neutered?

Yes
No
I don't know

Has your cat been tested for Feline Leukemia?

Yes
No
I don't know

Has this pet been tested for internal parasites within last 6 months?

Yes
No
I don't know

Flea/tick control?

No
Frontline
Bravecto
Other

If other, please list:

Is this pet currently on any drugs/medications/supplements?

Yes
No

If yes, please list:

Diet

Amount per day:

Are there any food intolerances/drug allergies?

Yes
No

Do you want a diet reccomendation?

Yes
No

Treats or table scraps (what and how often)?

Appetite

Increased
Normal
Decreased

Weight

Loss
Gain
Stable

Water Consumption

Increased
Normal
Decreased

Bad Breath?

Yes
No

Has your pet had a dental cleaning done?

Yes
No

Do you brush your pet's teeth?

Yes
No

Can we show you how?

Yes
No

Behavioral changes?

Yes
No

If yes, please describe:

Scratching?

Yes
No

If yes, where at and for how long?

Difficulty rising/symptoms of arthritis/stiffness?

Yes
No

Lameness

Yes
No

When was the last time this cat was outside?

How many cats do you have and do any go outside?

How many litter boxes do you have?

Anything else we need to know?

Feline Patient History Form