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Valley Veterinary Clinic Pet Lodge & Salon

4390 East Main,
Farmington, New Mexico
87402
Clinic: 505-326-2237
Kennel: 505-327-7732

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Feline Patient History Form

Home » Forms » Feline Patient History Form

Feline Patient History Form

Date
Date Format: MM slash DD slash YYYY
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?

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In this section

Boarding Form
Canine Patient History Form
Client Satisfaction Survey
Comments/Feedback
Feline Patient History Form
Make an Appointment Online
New Client Registration Form
New Client Registration Form (for Mobile Devices)
Prescription Refill and Food Order Request Form

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Valley Veterinary Clinic
4390 East Main
Farmington, New Mexico, 87402

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