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Patient History

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Required for all office visits

Owner's First Name*

Owner's Last Name*

Cat's Name*

Age*

Phone*

Are texts okay?*

Yes

No

Email*

Diet: My cat eats (Mark all that apply)

Dry food

Canned or semi-moist food

Treats

People food

Brand of food my pet eats

Type of people food my pet eats

My cat (Mark all that apply):

Is a picky eater

Will only eat dry food

Will only eat canned food

Will eat most types of cat food

Is always begging for food

My cat (Mark the choice that applies best to your cat):

Is always inside and never sneaks outside

Is mostly inside, but occasionally goes/sneaks outside

Goes inside and outside

Is always outside

My cat (Mark the choice that applies best to your cat):

Never comes in contact with other cats

Only comes in contact with the cats in our household

May come in contact with cats other than in our household

How many cats are in your household including this cat?*

If there are other cats in your household, do they go/sneak outside?*

Yes

No

N/A

Are there dogs in the home? If yes, are they currently vaccinated and on heartworm and flea preventive?*

Yes

No

N/A

Are all the cats in the home currently vaccinated and on heartworm and flea preventive?*

Yes

No

N/A

Are there children, expectant mothers or immunocompromised people exposed to your pet?*

Yes

No

Is your pet currently having problems with:*

Fleas

Ticks

Neither

Is your pet on monthly parasite preventative? If Yes, what brand?

Last date given

How consistent does your cat receive heartworm preventive?

Name (ex: Amlodipine)

Dose (ex: 5mg)

How often (ex: 1 per day)

Name

Dose

Frequency

Name

Dose

Frequency

Name

Dose

Frequency

Name

Dose

Frequency

Name

Dose

Frequency

Please check any conditions that apply to your pet:

Is there anything else you would like the doctor to know?

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Comments

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