Feline Exam Form

Feline Wellness Exam
Pet Parent*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Patient History

Please fully complete this form
YesNoUnsureUpdating it today
Indoor onlyMostly outdoorBoth indoor and outdoor
Pet's Name* is eating and drinking   *         . He/she eatsBrand/Type of food*.
Do you feed table scraps?*
Has he/she experienced any of the following symptoms in the last 5 days?   vomiting   not eating   diarrhea   sneezing   coughing   none of the above*
How long have these symptoms been going on?   *
Urine and bowel movement frequency and consistency isnormalabnormal   unsure*
Are there any lumps/bumps/growths that need to be checked today? Yes  No*

Please mark all that apply;
My pet is experiencing:
Inappropriate urination/urinating outside of the litter box   Pain/Discomfort while urinating/defecating   Bad Breath   Scratching Ears/Shaking Head  Drainage from eyes/nose   Squinting or Rubbing eyes Skin issues/rash/sores/infection   Abnormal vocalization   Open Wound   Trouble walking or standing   Limping
None of the above*
YesNo
YesNo
Yes, PleaseNo, Thank you
Please list ALL medications, vitamins and/or supplements that your pet is currently taking: You may type in NONE if your pet is not taking any medications;*
List of all current medications, vitamins and/or supplements
Rabies *Required by Law*RCPP (Feline Rhinotracheitis-Calici-Panleukopenia Vaccine)Decline RCPP VaccineFeLV (Feline Leukemia Virus Vaccine)Decline FeLV
Please list any additional questions or concerns you may have for the doctor so we can be sure to address them at this appointment.
Additional questions or concerns
Our standard of veterinary care is to do annual wellness blood work and fecal testing. Certain medications may require that your pet has blood work tested every 3-6 months. Please plan to bring a fresh fecal sample with you to your appointment if your pet is due for annual testing or is having stool concerns. If this is not possible, a sample may be collected at the time of the blood draw.
Thank you and see you soon!
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Feline Wellness Exam

Patient History