Patient History Questionnaire

UPDATE FOR 2026

Please be sure to fill this out in its entirety. Please 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!

At this time, we are unable to accept new clients to our practice. For existing clients who have added new cats to their household, please utilize the form below.

First Name

Last Name

Phone

Email Address

By providing my phone number, I consent to receive SMS text messages from Cats Exclusive for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg data rates may apply. Reply HELP for support. Reply STOP to opt out. Refer to our privacy policy and terms and conditions for more information.

I Consent to receive SMS text messages
I Do Not Consent to receive SMS text messages

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?

What's Mew

CBD for Cats: Not Pot for Cats

We in the Pacific Northwest are a savvy community when it comes to Cannabis. However, there can still be confusion about what is available and safe to use in a cat. It... read more

Happy Trails Dr. Alviar

To the people who have entrusted me with the care of our cats over the last six years: I am so deeply honored to have known you and your kitties. I cherish your wonderful stories and memories, from antics to creative names (and clothing, you Sphynxes!) to soul connections. read more

Susu's Tale of Two Too Many Teeth!

Susu is a little black cat I adopted as a kitten from a feral mom. I lovingly call him my “dirt baby” in homage to his humble, country roots. Because he consumes... read more

Our Store for Cats

At Cats Exclusive, your cat's health matters most. Whether your cat needs a healthy maintenance diet, or a special diet to meet a medical need, you will find a selection of excellent products here.

Learn More

St. Francis Fund

The Cats Exclusive St. Francis Fund was created in 2002 by our kindhearted doctors and staff to provide urgent, life-saving medical care for cats in need.

Learn how you can help!