ZenCat New Patient History Form

How did you hear about ZenCat? (Google, Yelp, referral, etc.)

Name

Owner's First NameOwner's Last Name

Owner's Date of Birth (this is sometimes required for prescriptions)

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner's occupation

Mobile Phone Number

Area CodePhone Number

Home Phone Number

Area CodePhone Number

Email

example@example.com

Email Used for Ordering on Chewy.com (I like to be able to pre-authorize prescriptions through Chewy, and this can help facilitate that, saving time)

example@example.com

Additional Owner's Name(s)

Additional Owner's Date(s) of Birth

Date

Additional Owner's Occupation

Additional Owner's Mobile Phone Number

Area CodePhone Number

Additional Owner's Email

example@example.com

Preferred method of contact (text, email, mobile phone, home phone, snail mail)

Number of cats in the home

Other pets in the home (specify)

How many square feet is your home?

Approximate square footage cat(s) has/have access to?

Number of cat litter boxes

Type of cat boxes (small, large, open, covered, automatic)

Brand/type of cat litter you use

Number of water fountains/bowls

What sorts of catification have you done (wall shelves, perches, scratching posts, cat trees, catio)

Do you currently use cat pheromone plug ins?

Information for First Cat

Cat's Name

Cat's Birthdate (if known, or estimated)

Date

Cat's Age

Breed

If Purebred, breed?

Color

Male or Female?

Spayed or Neutered?

How was this cat acquired (breeder, shelter, foundling, friend, failed foster, etc.)?

How old was this cat when s/he came into your life?

What is your relationship with this cat? (Your child, beloved family member, beloved pet, just a cat, semi-feral, feral, etc.)

Would you be comfortable restraining this cat for the doctor, if necessary?

Date of most recent vaccinations?

Which vaccinations were given?

Does this cat ever go outside?

Does this cat have a microchip?

What do you use for flea prevention?

Name of your current veterinarian

Name of your current veterinary practice/hospital

Current medical issues this cat is dealing with (specify)

Significant past medical history for this cat

What goes into this cat's mouth - wet food, dry food, treats, table scraps, lizards, etc. Please specify brands of foods, when available.

What else goes into this cat's mouth that isn't listed above - supplements, medications, etc.

How is this cat's appetite?

Is this cat thirsty?

Does this cat drink water frequently?

How is this cat's energy level?

Does this cat have a preference for warm or cool places?

Describe this cat's personality or overall emotional state

Does this cat sneeze? If so, how often?

Does this cat cough? If so, how often?

Does this cat vomit? If so, how often?

Does this cat have diarrhea? If so, how often?

Describe this cat’s stool.

Does your cat jump up normally?

Does your cat jump down normally?

Does your cat climb up stairs or steps normally?

Does your cat climb down stairs or steps normally?

Does your cat run normally?

Does your cat chase moving objects (toys, prey, etc.)?

Does this cat have any behavior issues that concern you? Please describe.

What are you hoping to accomplish for this cat during your house call. Please be specific.

If you are done filling out histories for your cats, please scroll to the bottom and click on the Submit button. Otherwise continue with your next cat history below.

Information for Second Cat

Cat's Name

Cat's Birthdate (if known, or estimated)

Date

Cat's Age

Breed

If Purebred, breed?

Color

Male or Female?

Spayed or Neutered?

How was this cat acquired (breeder, shelter, foundling, friend, failed foster, etc.)?

How old was this cat when s/he came into your life?

What is your relationship with this cat? (Your child, beloved family member, beloved pet, just a cat, semi-feral, feral, etc.)

Would you be comfortable restraining this cat for the doctor, if necessary?

Date of most recent vaccinations?

Which vaccinations were given?

Does this cat ever go outside?

Does this cat have a microchip?

What do you use for flea prevention?

Name of your current veterinarian

Name of your current veterinary practice/hospital

Current medical issues this cat is dealing with (specify)

Significant past medical history for this cat

What goes into this cat's mouth - wet food, dry food, treats, table scraps, lizards, etc. Please specify brands of foods, when available.

What else goes into this cat's mouth that isn't listed above - supplements, medications, etc.

How is this cat's appetite?

Is this cat thirsty?

Does this cat drink water frequently?

How is this cat's energy level?

Does this cat have a preference for warm or cool places?

Describe this cat's personality or overall emotional state

Does this cat sneeze? If so, how often?

Does this cat cough? If so, how often?

Does this cat vomit? If so, how often?

Does this cat have diarrhea? If so, how often?

Describe this cat’s stool.

Does your cat jump up normally?

Does your cat jump down normally?

Does your cat climb up stairs or steps normally?

Does your cat climb down stairs or steps normally?

Does your cat run normally?

Does your cat chase moving objects (toys, prey, etc.)?

Does this cat have any behavior issues that concern you? Please describe.

What are you hoping to accomplish for this cat during your house call. Please be specific.

If you are done filling out histories for your cats, please scroll to the bottom and click on the Submit button. Otherwise continue with your next cat history below.

Information for Third Cat

Cat's Name

Cat's Birthdate (if known, or estimated)

Date

Cat's Age

Breed

If Purebred, breed?

Color

Male or Female?

Spayed or Neutered?

How was this cat acquired (breeder, shelter, foundling, friend, failed foster, etc.)?

How old was this cat when s/he came into your life?

What is your relationship with this cat? (Your child, beloved family member, beloved pet, just a cat, semi-feral, feral, etc.)

Would you be comfortable restraining this cat for the doctor, if necessary?

Date of most recent vaccinations?

Which vaccinations were given?

Does this cat ever go outside?

Does this cat have a microchip?

What do you use for flea prevention?

Name of your current veterinarian

Name of your current veterinary practice/hospital

Current medical issues this cat is dealing with (specify)

Significant past medical history for this cat

What goes into this cat's mouth - wet food, dry food, treats, table scraps, lizards, etc. Please specify brands of foods, when available.

What else goes into this cat's mouth that isn't listed above - supplements, medications, etc.

How is this cat's appetite?

Is this cat thirsty?

Does this cat drink water frequently?

How is this cat's energy level?

Does this cat have a preference for warm or cool places?

Describe this cat's personality or overall emotional state

Does this cat sneeze? If so, how often?

Does this cat cough? If so, how often?

Does this cat vomit? If so, how often?

Does this cat have diarrhea? If so, how often?

Describe this cat’s stool.

Does your cat jump up normally?

Does your cat jump down normally?

Does your cat climb up stairs or steps normally?

Does your cat climb down stairs or steps normally?

Does your cat run normally?

Does your cat chase moving objects (toys, prey, etc.)?

Does this cat have any behavior issues that concern you? Please describe.

What are you hoping to accomplish for this cat during your house call. Please be specific.

If you are done filling out histories for your cats, please scroll to the bottom and click on the Submit button. Otherwise continue with your next cat history below.

Information for Fourth Cat

Cat's Name

Cat's Birthdate (if known, or estimated)

Date

Cat's Age

Breed

If Purebred, breed?

Color

Male or Female?

Spayed or Neutered?

How was this cat acquired (breeder, shelter, foundling, friend, failed foster, etc.)?

How old was this cat when s/he came into your life?

What is your relationship with this cat? (Your child, beloved family member, beloved pet, just a cat, semi-feral, feral, etc.)

Would you be comfortable restraining this cat for the doctor, if necessary?

Date of most recent vaccinations?

Which vaccinations were given?

Does this cat ever go outside?

Does this cat have a microchip?

What do you use for flea prevention?

Name of your current veterinarian

Name of your current veterinary practice/hospital

Current medical issues this cat is dealing with (specify)

Significant past medical history for this cat

What goes into this cat's mouth - wet food, dry food, treats, table scraps, lizards, etc. Please specify brands of foods, when available.

What else goes into this cat's mouth that isn't listed above - supplements, medications, etc.

How is this cat's appetite?

Is this cat thirsty?

Does this cat drink water frequently?

How is this cat's energy level?

Does this cat have a preference for warm or cool places?

Describe this cat's personality or overall emotional state

Does this cat sneeze? If so, how often?

Does this cat cough? If so, how often?

Does this cat vomit? If so, how often?

Does this cat have diarrhea? If so, how often?

Describe this cat’s stool.

Does your cat jump up normally?

Does your cat jump down normally?

Does your cat climb up stairs or steps normally?

Does your cat climb down stairs or steps normally?

Does your cat run normally?

Does your cat chase moving objects (toys, prey, etc.)?

Does this cat have any behavior issues that concern you? Please describe.

What are you hoping to accomplish for this cat during your house call. Please be specific.