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Feline Lifestyle Survey
To help us better understand your pets overall health it is important to know some basic information regarding your pet and their history and life style.
Owner Information
Date
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Month
-
Day
Year
Date
Owner's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Cell Phone:
*
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Pet Information
Pet's Name
*
Upload A Picture of Your Pet (Optional)
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of
Age of Your Pet
*
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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1924
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1922
1921
1920
Year
What breed of cat is your pet? (Domestic long hair, domestic short hair, siamese, manx, etc.)
*
Color / Distinguishing Marks
*
Sex
*
Male
Neutered Male
Female
Spayed Female
If female, has she ever had kittens? If so, how many litters and when?
*
If female and not spayed - when was her last heat cycle?
*
How old was he/she when spayed/neutered?
*
Is Your Pet Microchipped?
*
Yes
No
I'm not sure
Microchip Number (if known)
Has your pet ever had any reactions to medications?
*
Yes
No
Please provide us details on any reactions to medications your pet has had. What medications? What reactions? When did this occur?
Has your pet ever had any vaccine reactions?
*
Yes
No
Please provide us details on any reactions to vaccines your pet has had. What vaccines? What reactions? When did this occur?
Are there other pets in the house?
*
Yes, dogs
Yes, cats
No
Are the other pets in the household current on vaccines?
*
Yes
No
Do you observe wildlife in your area? Bats, ferral cats or dogs, chipmunks, skunks, squirrels, foxes, coyote, etc.
*
Yes
No
Travel & Outdoors
Does your cat ever go outside?
*
Yes
No
How much time does your cat spend outside?
*
Is your cat allowed to free roam outside? (Outside a fenced cattery or catio?)
*
Yes
No
Do you take your pet to any of the following? (Check all that apply.)
Boarding Facilities
Grooming Facilities
Other
Do you travel with your cat? If so, where (out of state?) and how often?
*
Vaccines & Preventatives
Has your pet had vaccines in the past year somewhere other than Bosque Animal Clinic?
*
Yes
No
Choose the vaccines your pet has had in the past in the last year IF NOT given by Bosque Animal Clinic
*
Rabies
FVRCP (AKA Upper respiratory vaccine or feline distemper vaccine)
Feline Leukemia
None
Where did your pet get their last set of vaccines? Veterinarian/clinic name?
*
When was your pet last vaccinated for rabies?
*
When was your pet last vaccinated for FVRCP/Feline upper respiratory vaccine/feline distemper vaccine?
*
Has your cat ever been tested for feline leukemia/FIV (feline HIV)?
*
Has your pet ever been seen by any other veterinarians besides at Bosque Animal Clinic?
*
Yes
No
What other veterinarian(s) has your pet seen? When?
Is your pet on heartworm preventative?
*
Yes
No
What heartworm prevention do you use?
*
Heartgard
Revolution
Other
Do you give heartworm preventative year around?
*
Yes
No
Where do you purchase your heartworm prevention?
*
Is your pet on flea/tick preventative?
*
Yes
No
What flea/tick preventative do you use?
*
Do you give flea and tick preventative year around?
*
Yes
No
Where do you purchase your flea/tick preventative?
*
When was your pet's last fecal exam to test for zoonotic intestinal parasites (roundworms, hookworms, tapeworms, whipworms, giardia, etc)?
*
Do you do anything for your pet's oral health? Brush teeth? Provide dental chews/treats or products? If so, please provide us details? How often do you brush, give dental chews/treats or use dental products? What are the names of the chews/treats and/or dental products us you?
*
Medical History
Do you do anything for your pet's oral health? Brush teeth? Provide dental chews/treats or products? If so, please provide us details? How often do you brush, give dental chews/treats or use dental products? What are the names of the chews/treats and/or dental products us you??
*
Is your pet on any over the counter supplements? If so, what, how much and how often?
*
Does your pet have any previous medical conditions? If so, please provide us details.
*
Has your pet had any previous surgeries (besides spay/neuter)? If so, please provide us details.
*
Diet & Appetite
What do you feed your pet?
*
Dry food
Canned food
Home made diet
Raw food
What is the brand of dry food you feed?
*
How much and how often do you feed?
*
Is the food you feed a grain free diet?
*
Yes
No
What is the brand of canned food you feed?
*
How much and how often do you feed?
*
Describe the home made or raw diet you give your pet? How much and how often?
*
Do you feed your pet any table foods (share your meals with your pet)? If so, what and how often?
*
Were there any recent changes to your pets diet?
*
Yes
No
What were the recent changes to your pets diet?
*
How is your pets appetite?
*
Normal
Increased
Decreased
Give us details on the changes in your pets appetite? When did it start? Any recent diet changes?
*
How is your pets water intake?
*
Normal
Increased
Decreased
Give us details on the changes in your pets water intake? When did it start?
Health Status
Has there been any changes to you pet's weight?
*
Weight gain
Weight loss
No, weight is stable
When did you first notice the change in your pet's weight?
Has there been any changes to your pets activity level?
*
Pet has been less active
Pet has been more active
No changes
When did you first notice the change in your pet's activity level?
*
Is your pet having normal and regular bowel movements?
*
Yes
No
Please provide us details on your pet's abnormal bowel movements. Diarrhea? Constipation? Increase in frequency?
*
Have you seen any worms in your pets bowel movements? If so, provide us details.
*
Is your pet urinating normally?
*
Yes
No
How many cats total do you have?
*
How many litter boxes do you have?
*
Please provide us details on your pets abnormal urination. Increase in frequency? Amount? Blood or abnormal odor? Straining?
Is your pet having problems with itching, scratching or excessive licking?
*
Yes
No
Please provide us details on your pet's excessive itching, scratching or excessive licking.
Have you seen any fleas or ticks on your pet?
*
Fleas
Ticks
None
Does your pet have any skin rashes or hair loss?
*
Yes
No
Please provide us details on your pet's rashes. When did it start? Have you applied anything topically or given any medications?
*
Is your pet sneezing, coughing or having breathing problems?
*
Yes
No
Please provide us details about your pets sneezing, coughing and/or breathing problems. When did they first start? When do they occur? How often? Are they seasonal? Associated with excitement?
*
Does your pet have any eye or nose discharge?
*
Yes
No
Please provide us details on the eye and/or nose discharge your pet is experiencing. When did it start? How often does it occur? Is it clear, yellow, green? Etc.
*
Have you noticed any problems or changes in your pets vision?
*
Yes
No
Please provide us details about your pets change in vision. When did you first notice the changes?
*
Does your pet have any lumps or bumps?
*
Yes
No
Please provide us details about your pets lumps or bumps? When did you first notice them? Have they gotten bigger? Are they causing pain or discomfort for your pet? Etc.
*
Does your pet have any aches or pains? Slow to rise or lay down? Hesitant to jump on coach, bed or in vehicle?
*
Yes
No
Please provide us details about your pets aches or pains? When did it start? Any associated trauma? Etc.
*
Is there any recent known toxin exposure?
*
Yes
No
Unknown
Please provide us details on your pets recent toxin exposure. What? When? Where?
*
Is there any recent known trauma?
*
Yes
No
Unknown
Please provide us details on your pet's recent trauma. What? When? Where? How?
*
Has your pet had any history of seizures?
*
Yes
No
Please provide us details on your pets seizure history? When did they start? How frequently do they happen? Any known triggers? Any current medications? Any history of head trauma?
*
Has your pet had any changes in behavior or attitude?
*
Yes
No
Please provide us details on the changes in behavior or attitude your pet is changing. When did it start? What changes have occurred? Have you tried any medications or supplements to help?
*
Does your pet suffer from anxiety?
*
Yes
No
Please provide us details on your pets anxiety? When does it happen? How often? Any known triggers? Have you tried any medications , over the counter supplements or behavior modification?
*
What is the primary reason for today's visit?
*
Do you have any specific questions or concerns you would like to address today?
*
Signature
*
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