Please Print, fill out in detail and bring with you when bringing your kitty in for an exam.
Pet's Name (required)
Owner's Name (required)
Date form filled out: (required)
Your Email (required)
History: Please provide as much information as you can. This will help us accurately diagnose and treat your pet. Please be as specific as possible (e.g. “right eye red and itchy for 3 days” rather than “eye problem”). 1) Do you have any concerns about your pet’s health today?
2) Other than flea-tick medication, any other medications, nutritional supplements or herbal medications given? YesNo List all include how often given and last time given. Please include eye or ear meds, medicated shampoos, SQ fluids, prescription diets and any long term medications
3) Coughing Recently? YesNo If Yes then answer the following: When did coughing begin? Worse at any time of the day or night (e.g. when sleeping, after exercise)? Has he or she been boarded recently or groomed? Any additional comments about the cough?
4) Sneezing Recently? YesNo If Yes then answer the following: When did the sneezing begin? When your pet sneezes, is there any discharge? If so, what color? Has he or she been boarded or groomed recently? Been exposed to any strange cats? Any additional comments about the cough?
5) Any difficulty breathing? YesNo If Yes then answer the following: When did you first notice? Does your pet ever breathe with its mouth open? Does your pet sound congested? Do you hear your pet wheezing?
6) Any Eye or Nose discharge recently? YesNo If yes, EyesNose
7) Vomiting Recently? YesNo If Yes then answer the following: When did the vomiting begin? How many times has your pet vomited in the last 24 hours? When was the last time he or she vomited? What did he or she vomit first (e.g.water, bile, foam, food)? Has any blood been seen in the vomit? If yes, was the blood bright red or dark reddish-black? Any chance your pet ate something he or she shouldn’t have? Any additional comments?
8) Diarrhea Recently? YesNo If Yes then answer the following: When did the diarrhea begin? When was the last time your pet had diarrhea? Does he or she strain when they have the diarrhea? What color is the diarrhea? Any clear, jelly-like mucous? Has any blood been seen in the diarrhea? If yes, was the blood bright red or dark red? Any chance your pet ate something that they shouldn’t have? Any additional comments?
9) Is your pet excessively thirsty? YesNo
10) Is your pet drinking enough water? YesNo
11) Is your pet urinating normal amounts? YesNo If No, is it more or less than normal?
12) Is your pet urinating where he or she should? YesNo If No then answer the following: Is this a new problem? Where is your pet urinating that they aren’t supposed to? Have you seen him or her pee recently? Was there any straining? Did the urine look normal? Was there any blood in the urine? Have you noticed your pet licking his or her privates more?
13) Did your pet eat this morning? YesNo
14) Is your pet eating normal amounts? YesNo If No then answer the following: How long has the appetite been abnormal? Is he or she pickier or not eating at all? If anything, what will your pet eat now?
15) What does your pet normally eat? Please be specific as to brands, etc. How much and how often?
16) Is there any possibility your pet ingested or was exposed to a household chemical or toxin, or ate a rodent or plant? YesNo If Yes, please explain:
17) Is your pet excessively itching/scratching? YesNo If Yes, what areas on the body are most itchy?
18) Are your pet’s ears bothering him or her? YesNo If Yes, is it one or both ears? Is one ear worse than the other?
19) Is your pet limping? YesNo If Yes, then answer the following: Which leg? How long has it been going on? Is it worse after resting/sleeping?
20) Any fleas or ticks recently? YesNo If Yes, please explain
21) Is your pet strictly an indoor cat? YesNo If Yes, please answer the following: Any porch privileges? Outside supervised at all? Any escapes?
