Cat Pre-consult Questionnaire

16 Dalham Road Kimberley KIMBERLEY8301 Tel: 053 832 5711
Please complete the following form prior to your appointment. If there are certain things you do not know or cannot answer, please feel free to leave those sections blank.

Thank you for trusting us with your whiskered friend. We look forward to seeing you!
Your Cat's Name
Your Cat's Nickname
Name and Surname
Preferred Contact Number
Email Address
example@example.com
PET DETAILS:
Age/Date of Birth

MonthDayYear
Date
Male/Female*
Sterilised
Breed
Description/Colour
Reason for Visit (Description of Symptoms)*
Date that symptoms started

MonthDayYear
Date
How have the symptoms progressed? Are they IMPROVING / STAYING THE SAME / GETTING WORSE
Date of last vaccination

MonthDayYear
Date
Date of last deworming

MonthDayYear
Date
Date of last tick and flea treatment

MonthDayYear
Date
Has your cat been tested for FIV or FeLV?
What were the results? (Positive/Negative)
If so, when was your tested for FIV/FeLV?

MonthDayYear
Date
What cat food is your cat being fed (Detailed food menu, snacks included!)
Does your cat have food freely available, or do you feed measured amounts of kibble per day?
Any previous veterinary diagnosed illnesses/diseases within the last 12 months
Is your cat on any chronic/prescribed medication? (Please list)
Is your cat an INDOOR / OUTDOOR / INDOOR-OUTDOOR cat? (Please type the option that fits best)
INDOOR/OUTDOOR/INDOOR-OUTDOOR
Have there been any changes in the following:
Eating habits
Drinking habits
Toileting habits
Please list other pets in your home (species and breed)
How many litterboxes are in your home and where are they located?
Do your cats share a food/water source?
Have there been any recent changes within your household (Pets included)?
Tell us some Fun Facts about your pet! (Is he a cuddler, a pro hunter, bed hogger, etc. Anything is okay!)
Thank you for completing the pre-consultation questionnaire. If there is any other information you may remember before your appointment that you have not included in this form, please write it down and give it to the veterinarian while in the appointment.
Should be Empty:

PET DETAILS: