New Client Feline Health History Latham Animal Hospital

New Client Feline Health History Latham Animal Hospital
DateTime
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should another person be listed on account?

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Email
example@example.com
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.
Pet's name
My pet:
Birth Date

MonthDayYear
Breed:
Sex:
Is your cat on any prescription or homeopathic medications or supplements?
I hereby authorize the veterinary hospital to examine, prescribe, and treat my pet. I assume financial responsibility for all charges accrued through the treatment of my pets. I understand that payment must be made at the time of treatment and that I may be asked for a deposit for emergency and surgical treament.
Signature
My cat's story
My cat joined my family as
My cat lives in a/an
My cat lives with
To me, my cat is: (please check all that apply)
With people, my cat
With dogs, my cat
With other cats, my cat
Bringing my cat to the vet is
Is there anything you would like to add to your cat's story?
My cat's exercise and nutrition assessment
My cat is
When my cat is "home alone". s/he is
My cat is outside
For exercise, my cat (check all that apply):
For primary nutrition, my cat eats (check all that apply):
My cat eats
I give my cat
For treats, I use (check all that apply)
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)
I travel with my cat
My cat likes to get into (check all that apply)
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)
What dental care do you do at home? (check all that apply)
And their eyes:
My cat's eyes (check all that apply)
Ears:
My cat's ears (check all that apply):
Heart and Lungs:
My cat (check all that apply)
Skin and Body:
My cat's coat and body (check all that apply)
Mobility and movement:
My cat(check all that apply)
Weight and appetite:
My cat (check all that apply)
GI system:
My cat (check all that apply)
Behavior and Cognition:
My cat (check all that apply)
Have there been any other health changes that we should be aware of?
Are there any other questions you would like us to address at your next visit?
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.
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New Client Feline Health History Latham Animal Hospital

My cat's story

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: