Patient History Questionnaire

Patient History Questionnaire

Please be sure to fill this out in its entirety. This form is used for both new patients/clients and returning patients coming in for their annual wellness exams, so be sure to carefully review each question to denote the best answer for your kitty. Our goal is to provide you with the most accurate medical advice to enhance the quality of your feline family member's life. Thank you!

*If no, please be sure to have also filled out the Client Information Form.

If Yes, please describe

If Yes, when was the test performed?

If Yes, when/what dewormer given?

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 #1

Drug #2

Drug #3

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

Please choose one of each of the following:

If Yes, please describe:
Cat Friendly
Enviro Star Certified
Care Credit