Kitten History Chart 2.0

1
Will you be leaving your kitten here for their exam 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 kitten's name next!
First Name
Last Name
3
What is your kitten's name?* This field is required.Fill in your kitten'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?
Area Code
Phone Number
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 kitten's diet* This field is required.use the box above 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
Please Select
Yes
No
I'm not sure how much they are eating or drinking.
Have you noticed any changes in the amount they eat or drink?
Please Select
rodents and birds
crickets and insects
human flesh!
only their food bowl
What do they hunt?
How many cups of food a day (total) do they eat ?
Please Select
Please Select
Yes
No
I'm not sure
Is your kitten on a grain free diet?
9
Where does your kitten hang out?* This field is required.Tell us about your kitten's favorite places to stay, choose all that are appropriate
Inside only
Inside only, but their roommate 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 kitten is on...
Heartworm preventative
Monthly Flea and tick preventative
Joint supplement
Over the counter pain meds
Herbal medication
Prescription medicine
I need a refill
Other
11
Almost done!* This field is required.Check any of the boxes below that apply to your cat
I'm worried about my kitten's breath and dental health
I have seen behavior changes.
I have questions about vaccines or declawing my kitten.
My kitten is vomiting or losing weight
My kitten has a skin or ear infection
My kitten is having accidents in the house
I have no health concerns today
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
Chewing on things they shouldn't
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
Laser lights
Cat toys
Human flesh
Other kittens
Objects around the house
Plants
They don't really play
What things does your kitten like to play with/
13
Kitten Behavior QuestionsTell us more about your kitten's behavior
Please Select
Climbing furniture or screens
Ambushing humans from under furniture
Biting or scratching when petted
Urinating or defecating in the wrong spot
Trying to run outside
Chewing on plants
Other
What things are they doing?
Please Select
Kitten toys
Laser light
Other kittens
My hands and feet
Other
What toys do you have for them?
Please Select
Please Select
In a bed with humans
In a cat bed
Under furniture
Sleep, what sleep?
Other
Where do they like to sleep
Please Select
Water pistol
Tape
Alarms
Yelling
Trimming their nails
Nothing
What corrections 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 0.2lb in the last month
Drinking more than 12 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
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
opt3
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 (choose all that apply)?
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 time? Choose all that apply
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 and in the box
Formed and outside the box
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:
Is there anything they may have eaten to set this off? Choose all that apply
How many litter boxes do you have?
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 accidents in the house? Choose all that apply
How many cats are in the house total?
Should be Empty: