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Feline Wellness Questionnaire
Feline Wellness Questionnaire
20
Questions
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1
Your Name
*
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First Name
Last Name
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2
Pet's Name
*
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3
Phone Number
Area Code
Phone Number
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4
Email
example@example.com
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5
What is the date and time of your appointment?
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6
Has there been any prior drug, vaccine reactions or do you know of any allergies?
*
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7
List all current medications (including heartworm, flea and tick)
*
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8
Do you need any refills today on the medications just listed?
YES
NO
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9
Can you please bring a fresh stool sample to the appointment?
YES
NO
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10
What do you feed your cat: (Please include food brands, the quantity, & the feeding frequency)
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11
Does your cat go outside?
YES
NO
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12
If yes, do you notice other cats in your area that are outside?
YES
NO
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13
Do you have any other household pets? (What kind and how many)
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14
Is your cat microchipped?
YES
NO
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15
Does he/she resent being handled, picked-up or touched?
YES
NO
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16
Is it a struggle to get him/her in the cat carrier?
YES
NO
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17
How many litter boxes do you have in your house. Please specify where they are located and what kind of litter is used (clumping vs. non, scented vs. non)
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18
Any coughing, sneezing, vomiting or diarrhea? If so, please elaborate.
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19
If your cat is an adult (1 yr+), we may perform annual wellness bloodwork that includes a stool sample and urinalysis. Is this something we can do at the time of your visit with us?
YES
NO
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20
Do you have any concerns to address with us?
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