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!

First Name

Last Name

Phone

Email Address

Cat's Name

Cat's Date of Birthdate/Age

Cat's Breed (DSH, DLH, Persian, etc.)

Coat Color (Brown Tabby, Tuxedo, Tortoiseshell, etc.)

Sex of Cat

Spayed/Neutered

Have you been to our clinic with this or any other cats before?
Yes No
*If no, please be sure to have also filled out the Client Information Form.

Will this be this cat's first visit to our clinic?
Yes No

Was this a recent shelter/rescue adoption?
Yes No
If Yes, please denote the name of the shelter and date of adoption:

Primary reason for this appointment request/current medical concerns:

Do you already have an upcoming appointment scheduled at our clinic?
Yes No
If Yes, Date/Time:

If this is your cat's first visit to our clinic, we will need to gather all previous medical history. Please list the name(s) of all veterinary clinics your cat has been to in the past 7 years. This includes general practice visits, emergency care, specialty centers, etc. Please be sure to denote if records might be under a different cat or client name.

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 #1

Name of Drug

Dose

How Often

When Started

Dose Given Today

Drug #2

Name of Drug

Dose

How Often

When Started

Dose Given Today

Drug #3

Name of Drug

Dose

How Often

When Started

Dose 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

Activity Level

Drinking

Urination

Are there any problems with litter box use or behavior?
Yes No
If Yes, please describe:

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

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