Cat History Chart 2.0

1
Will you be leaving your cat here today for examination and treatment?* This field is required.Answer "yes" if this is a drop off appointment
YESNO
2
Your Name* This field is required.Don't worry, we'll ask your cat's name next
First Name
Last Name
3
What is your cat's name?* This field is required.Fill in your cat's name that we are seeing today:
4
Email* This field is required.We need your email to send you lab results, health reminders and health updates. We don't spam it!
example@example.com
5
Phone Number* This field is required.What is the best number to reach you at during the day?
6
Authorization of medical treatmentBe advised that you are leaving your pet here today because a doctor is not available for immediate examination. If you feel that your pet's condition is deteriorating or that they may die, we recommend taking them immediately to the Veterinary Emergency Hospital In Sioux Falls and not leaving them here. When the doctor has a chance to examine your pet, the medical team will call the number you have left on this submission form and discuss diagnostics, treatment options and cost. If your patient's condition becomes life threatening at any point do you want:
CPR
Do not resuscitate
7
What health concerns do you have today?Type in all of your concerns, and we will make sure we address them today!
Huge
Large
Normal
Small
Ok
Ok
8
Tell us about your cat's diet* This field is required.use the boxes below to tell us what foods make your cat purr...
Fill in all the foods your cat likes (dry, canned, dental treats, people food, treats.) and brands if you know them.
Please Select
Food is always available
Once a day meal feeding
Twice a day meal feeding
Three or more times a day
How often do you feed your cat? Choose all that apply.
Please Select
rodents or birds
crickets or insects
human flesh!
only the food bowl
Other
What does your cat hunt?
How many cups of food a day (total) do they eat ?
Please Select
Please Select
Yes
No
I'm not sure how much they are eating or drinking.
Eating and drinking normally?
Please Select
Please Select
No, thank you.
Yes, I have questions.
I only want to discuss this if medically necessary.
Questions about the diet?
Please Select
Please Select
Yes
No
I'm not sure
Does your cat eat grain free diet?
9
Where does your cat hang out?* This field is required.Tell us about your cat's favorite places to stay, choose all that are appropriate
Inside only
inside only but they have a roommate that goes outside
In spots with altitude (shelf, tree, back of couch)
Under things
Outside on a leash
Outside in a fenced yard
Outside off leash
Boarding
Travels out of state
Camping
Other
10
Medications* This field is required.Choose all of the medications that your cat is on...
Heartworm preventative
Monthly Flea and tick preventative
Joint supplement
Over the counter pain meds
Herbal medication
Prescription medicine
I need a refill
Not on any medications
Other
11
Almost done!* This field is required.Check any of the boxes below that apply to your cat
I'm worried about my cat's breath and dental health
My cat isn't as active as they used to be or is acting lame
My cat's behavior has changed from the last visit
My cat is vomiting or losing weight
My cat has a skin or ear infection
My cat is having accidents in the house
My cat has a lump
I have no health concerns
Other
12
Dental QuestionsTell us more about your cat's teeth:
Please Select
Bad breath
Loose teeth
Broken or discolored teeth
Sore when they eat
Swelling around the face
Not grooming themselves
Choose all of the following problems your cat has
Please Select
I don't have a dental routine
I give them dental treats
I brush their teeth at home or put on a sealant
I have their teeth professionally cleaned
Tell us about your dental routine for your pet:
Please Select
Please Select
Never
Less than 1 year ago
1-2 years ago
Over 2 years ago
When was their last dental cleaning with x-rays
13
Lameness QuestionsTell us more about your cat's lameness...
Please Select
Left front leg
Right front leg
Left rear leg
Right rear leg
Neck
Back
Not sure
Where are they sore?
Please Select
All the time
When they wake up, then it gets better during the day
Only after exercise
At night
When are they sore?
Please Select
Please Select
It waxes and wanes
Less than 1 week
1 week - 1 month
More than 1 month
How long have they been sore?
Please Select
Rest
Ice
Heat compress
Prescription meds
Over the counter meds
Nothing
What therapies have you tried at home?
Please Select
Please Select
Yes
No
A little
Did anything help?
14
Vomiting or weight loss questionsChoose all the symptoms you have noticed in your cat
Weight loss over 0.5lb in the last 6 months
Drinking more than 20 ounces of water a day
Filling the litter box with more than 15 urine spots a week
Vomiting hair balls
Vomiting partially digested food
Vomiting clear liquid
More active than normal
Crying or vocalizing
Other
15
Skin and Ear questionnaireTell us about your cat's problems
Please Select
Red skin
Red bumps on skin
White scales on the hair
Scratching/itching
rubbing face
Rubbing bottom on the floor
Hair loss
Licking feet
Licking other parts of the body
Ear infection
Bad odor
Infections around the mouth or eyes
Broken nails
Weird looking foot pads
Vomiting or diarrhea
Flatulence (gassy)
Frequent, large soft bowel movements
Other
What symptoms are you seeing at home?
Please Select
Year round
Spring
Summer
Fall
Winter
What seasons of the year do you see these problems?
Please Select
Please Select
Never gets over them
Weekly
Monthly
Every 3-6 months
How Frequently does your cat get infections?
Please Select
No
Other dogs
Other Cats
People in the house
Does anyone else have a skin infection?
Please Select
Inside
Outside on cement only
Outside on mowed grass
Outside in tall grass
Around other cats
Where does your cat spend their day?
Please Select
Monthly heartworm preventative
Monthly flea / tick preventive
Medicated baths
Allergy meds
Antibiotics
Topical sprays
Fish oil supplements
Choose all the meds that your cat is on
Please Select
Stored in the original bag
Stored in a plastic container
Food and water in a metal bowl
Food and water in a ceramic bowl
Food and water in a plastic bowl
How is the food stored and fed?
16
Accidents in the house QuestionnaireTell us what type of problem you are having
Please Select
Formed
Soft, pudding like
Watery diarrhea
Blood in the stools
I haven't seen a stool in over 48 hours
How are the stools? Check all that apply
Please Select
No vomiting
Vomits <30 minutes after they eat
Vomits hours after they eat
Vomits partially digested food or feces
Vomits yellow bile liquid
Vomits blood or dark brown coffee grounds
Is there any vomiting? Choose all that apply
Please Select
No, they only eat cat food.
Human food
Garbage
Lawn or cleaning chemicals
Foreign body like a tinsel or rubber band
String from a blanket or toy
They are on medication:
Did they eat anything unusual?
# of litter boxes in the house?
Please Select
No accidents in the house
No, but my cat strains over the litter box
They urinate in the box, but it is too frequent or too much
Urinate outside the litter box
I have seen blood in the urine
Other
Are there any urine spots in the house?
# of cats total in the house?
17
Lump QuestionsTell us about your cat's lump
Where are the lumps located?
Please Select
Please Select
I don't know
Less than 1 week
More than 1 week
How long has the lump been there?
Please Select
The lump is rapidly growing
The lump is painful
The lump has discharge
I'm worried about cancer
I want it removed
Check all that apply
Should be Empty: