Appointment Questionnaire

Appointment Questionnaire

Please share how your pet is currently doing for their upcoming appointment!
Owner's Name*

First NameLast Name
Owner's email address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient History
Pet's Name*
Appointment Date

MonthDayYear
Date
What are you currently feeding and how much?*
Have there been any changes in your cats eating or drinking patterns?*

Eating less foodDrinking less waterEating more frequentlyDrinking more frequentlyNo changes in eating & drinking habits
Is your cat still able to jump up onto things? Are there any changes in their mobility to share with the Doctor?*

No changes in mobility to reportMy cat is experiencing changes in their mobility
Please note the mobility changes that have occurred and how long they have been experiencing these symptoms:
Have there been changes in bowel movements or urination?*

No changes to reportChanges in bowel movementsExcessive urinationLess urinationUrinating inappropriately
How many litter boxes do you have and where are they located?
Are your litter boxes covered or uncovered?

CoveredUncoveredMy cat goes outside
How many cats are in your home?
How often do you scoop the litter boxes?
How often do you change the litter in the box and clean the box?
What type of litter do you use?
Have you recently changed the type of litter you use? If so, how long ago?
Is the cat squatting or urinating on vertical surfaces?
Have there been any major changes in the household (such as moving, company, etc.)?
Is your cat strictly indoors, or does he/she go outside?*

Strictly IndoorsStrictly OutdoorsSpends time both indoors & outdoors
Has your cat been tested for FeLV/FIV?*

YesNoUnsure
Is your cat currently on flea control?

YesNo
What type of flea control do you use and when was it last applied/given?*
Do you have any current concerns or questions for the doctor?*
Should be Empty:

Appointment Questionnaire

Patient History