Patient History Questionnaire

Please answer All the questions by checking Yes or No. If Yes, please fill in all the blanks or check the options that apply. Your answers are VERY IMPORTANT. Our goal is to provide you with the most accurate medical advice to enhance the quality and quality of the cat's life. Thank you!

First Name

Last Name

Phone

Email Address

Cat Name

Cat Description

Is your cat Indoor Only Outdoor Only Indoor/Outdoor

If outdoor, what type of outside access does your cat have?

What do you feed your cat currently? Please be as specific as possible; include amount and frequency.

Has your cat ever had any vaccine reactions? Yes No

If Yes, please describe

Has your cat been tested for FELV/FIV? Yes No

If Yes, when was the test performed?

Has your cat been dewormed? Yes No

If Yes, when/what dewormer given?

Do you use any flea preventative? Yes No

If Yes, what products do you use and when were they last administered? Please include environmental products.

Please list current medications (including over-the-counter medications, nutritional supplements and herbal medications):

Drug Name	Dose	How Often	When Started	Given Today?

Has your cat recently exhibited any of the following signs (check all that apply)?

Vomiting
Difficulty Jumping
Diarrhea
Watery Eyes or Nose

Coughing
Increased Vocalization
Sneezing

Please choose one of each of the following:

Appetite:	Decreased	Increased	Normal
Activity Level:	Decreased	Increased	Normal
Drinking:	Decreased	Increased	Normal
Urination:	Decreased	Increased	Normal

Are there any problems with little box use or behavior? Yes No

If Yes, please describe:

Are there any other concerns you would like to address with the doctor?

Please add me to the mailing list.