Feline Lifestyle Assessment Form

Pet Owner Name:

Name of Cat:

Breed:

Date of Birth:

Date

Date of last preventive care visit:

Date

1. How many cats live in your home?

2. How many dogs?

3. Other pets in the household include:

4. Do you take your cat to any of the following (check all that apply):

5. How much time does your cat spend outside every day?

6. Do you take your cat on any outdoor activities?

7. Do you observe wild animals or other wildlife in your neighborhood?

8. Do other pets come to visit at your house?

9. Do you or your cat visit homes where there are pets?

10. Does anyone with compromised immune systems live in or visit your home?

11. Have you seen evidence of fleas, ticks or worms on any of your pets or in your home?

12. Have you noticed any fleas or ticks on your cat?

13. Does your cat use the litter box, go outside, or both

14. Please list all of the products, medications or supplements your cat is using:

Flea or tick control products

Pain medications (including prescriptions, aspirin or supplements)

Heartworm Preventative

Dental products (including chews)

Others

15. What kind of exercise does your cat get?

16. What kind of diet do you feed your cat?

17. Do you feed your cat treats?

If so how many times per day?

18. Have you noticed any of the following: Any weight loss or gain, change in your cats skin or hair coat, change in behavior or activity level? Pain as in slow to get up or down, tremor or weakness in the rear legs, protecting of a certain body part. Changes in behavior arounnd the litter box?

Please describe the changes