Feline Health History Latham Animal Hospital

Feline Health History
Date
Pet's name *
Your last name*
Phone Number

Area CodePhone Number
Client health screening: please complete this survey prior to coming to our hospitals to inform us of any risk to our team members. We do require face coverings for all clients coming within six feet of our employees.
Please check all that apply so we may take appropriate precautions.

I have confirmed Covid 19 or am under quarantine for due to exposure riskI have symptoms of illnessI have been exposed to Covid 19 through travel to an at risk regionI do not have any Covid 19 risk factors at this time.
My cat's exercise and nutrition assessment
My cat is
My cat is outside
For exercise, my cat (check all that apply):

believes that exercise is something dogs and people do.plays with cat toys and various things they knock off the table.jumps up and down from the counters and tables all the time.loves chasing mechanical toys and/or a laser pointer.has a cat tree or structure that s/he climbs around on.can play with a box for hours.plays fetch or chase games with me.plays and tumbles with other cats in our home.
For primary nutrition, my cat eats (check all that apply):

a homemade diet.a raw food diet.a high quality commercial dry food.a high quality commercial wet or moist food.a prescription diet.a commercial name brand dry food.a commercial name brand wet food.a store brand dry food.a store brand wet food.only people food.
For treats, I use (check all that apply)

commercial cat treats in a bag.homemade cat treats.fresh or frozen vegetables.kitty ice cream.table scraps and leftovers.cheese or meat bits.fish pieces dried or raw.Other
Is there anything you would like to add or ask about regarding your cat's exercise and nutrition?
Environmental Risks
My cat likes to visit (check all that apply)

no one-strictly indoor kittyour vet!our favorite pet boutique or store.friends with other petsthe neighbors--nearby fieldsponds, streams, and woodsout on the street--harness trained.therapy cat-schools/hospitals/nursing homes
My cat likes to get into (check all that apply)

catniphair ties, strings, or rubber bandshouse plantsthe trashanything in the kitchengrassmice and rodents--brings them to my door as a present
For heartworm prevention, my cat
For fleas and ticks, I use
Does your cat have any special environmental risks we should know about?
Health Survey:
Let's start with their mouth:
What about your cat's mouth? (check all that apply)

looks great with pearly whitesseeing some tartarseems to have quite a bit of tartarmy cat is drooling frequentlygums look pink and healthygums are a bit red and irritatedgums are very red and seem sorestill has "kitten breath"catch a whiff of bad breath sometimesbreath leaves something to be desiredughh--serious fish breath
What dental care do you do at home? (check all that apply)

uhmmm-not much really-my cat would kill meuse dental chews or treatsuse water additivesbrush my cat's teeth on occasionbrush my cat's teeth regularlyhave annual dental scale and polish
And their eyes:
My cat's eyes (check all that apply)

are clear and shiny.have some redness and irritation at times.have a gunky discharge sometimes.are frequently irritated and draining.are getting cloudy.are of concern. My cat is bumping into things.
Ears:
My cat's ears (check all that apply):

seem fine.have some gunk and debris once in awhile.always seem to have some debris.sometimes have a yellow or brown discharge.seem red or swollen on the inside.seem swollen or irritated on the outside.seem itchy. S/he scratches them frequently.are of concern. My cat does not seem to hearing as well as s/he used to.
Heart and Lungs:
My cat (check all that apply)

seems to be fine--no changes noted.seems to cough, sneeze, or gag more that s/he used to.seems to pant more frequently than s/h used to.has changed his or her meow.seems to get out of breath easily.seems to be more anxious, and I feel like his or her heart is beating faster at times.is vocalizing more frequently and seems agitated.
Skin and Body:
My cat's coat and body (check all that apply)

is shiny and fine.is dull and not as soft as it used to be.is oily and flaky.is dry, and appears to be itchy.seems to have an odor, and I see some crusty skin.has changed this year, and I am seeing some hair loss.has some open sores at times that seem to heal by themselves.has open sores that do not heal.gets little pimples that sometimes open up.has some lumps and bumps.has patches of hardened or thickened skin.is prone to hot spots at certain times of the year.
Mobility and movement:
My cat(check all that apply)

is still running around without a care in the world.seems awkward sometimes and limps once in awhile.is playing like usual, but occasionally seems to overdo it.is playing less than s/he used to, but still gets around okay.is slowing down and does not seem as interested in play.is stiff and has difficulty with stairs and climbing.seems to be painful sometimes when moving around.can no longer jump up on furniture the way s/he used to.is stumbling more than s/he used to.
Weight and appetite:
My cat (check all that apply)

is still at the same weight and eating and drinking as usual.has not gained or lost weight this year.has gained weight this year eating the same amount of food.has gained weight and is eating more.has gained weight but s/he is actually eating less.has lost weight this past year due to diet and exercise changes.has lost weight but is still eating like s/he used to.has lost weight and is eating less.seems to be hungry all the time.seems to be thirsty all the time.is drinking more water than s/he used to.seems to have trouble eating his/her normal food.
GI system:
My cat (check all that apply)

is urinating and defecating as usual.is having trouble controlling his/her bladderis not using the litterbox consistently.seems to be urinating more frequently.seems to be defecating more frequently.has strong smelling urine.has unusually strong smelling stools.has frequent loose stools.seems to get constipated.seems to get nausea more frequently.seems to vomit more frequently.eats houseplants.seems to have a sensitive stomach.frequently gets into stuff s/he should not eat.has a cast iron gut-nothing bothers him or her.
Behavior and Cognition:
My cat (check all that apply)

is acting like the happy cat s/he is.has not had any behavioral changes.has had behavioral problems in the past but they have improved.continues to struggle with behavioral problems (please let us know what these are)is showing some increased anxietyis showing some increased aggressionsometimes seems confusedis not as responsive to us as s/he used to beis lethargic and sometimes acts depressed
Have there been any other health changes that we should be aware of?
What is your primary concern for today?
Thank you so much for completing this survey. We appreciate your deep knowledge of your pet, and this helps us partner more effectively with you to develop the best preventive care plan tailored to meet your pet's and your family's needs.
Should be Empty:

Feline Health History

My cat's exercise and nutrition assessment

Environmental Risks

Health Survey:

Let's start with their mouth:

And their eyes:

Ears:

Heart and Lungs:

Skin and Body:

Mobility and movement:

Weight and appetite:

GI system:

Behavior and Cognition: