Health Questionnaire
Welcome to the Pacific Cat Clinic! Please take a moment to answer a few questions.
Your Name:
*
First Name
Last Name
Your Cat's Name:
*
Why is your feline friend visiting us today?
*
What medication(s) is your cat taking? (Name, Dosage, Frequency)
What supplement(s) is your cat taking? (Name, Dosage, Frequency)
What food is your cat eating? (Dry/Wet, Brand, Frequency, Amount)
*
Please complete the following:
*
YES
NO
Has your cat had flea/worm preventative in the last year?
Does your cat have a microchip/tattoo?
Do you have pet insurance for your feline friend?
Has your cat travelled off the island in the last 5 years?
Does your cat regularly go outdoors?
Do you have any other pets at home?
Does your kitty feel nervous or defensive at the vet clinic?
In the past two months, have you noticed any of the following?
*
YES
NO
Vomiting (including hairballs)
Increase or decrease in appetite
Increase or decrease in thrist
Change in urination habits or volume
Change in consistency or frequency of stool
Defecation or urination outside the litter box
Scratching in a problematic area (couches, etc.)
Bumps, rashes, or itchy areas on their skin
Coughing or sneezing on a regular basis
Any other changes to your cat's normal routine
Problems walking/jumping/running
Please verify that you are human
*
Submit
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