Feline Clinical Medical History

Please complete this form thoroughly. The information you provide will help the doctor understand your cat's history and help provide the best possible treatment.
Caregiver's Name

First NameLast Name
Cat's Name
Cat's Date of Birth

MonthDayYear
Date
Cat's Weight
Photo of your cat

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Photo of your cat's tongue

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Video (link) of your cat walking toward camera, away from camera and from the side. Upload to YouTube and provide a link.
Tell us a little about your cat and the current situation concerning you.
Please list ALL current medications and supplements your cat is taking, including dose and frequency. Include flea/tick preventive.
Does your cat prefer taking medications in liquid, powder, or pill form?
Please list ALL food and treats your cat currently eats. Include foods given by others (friends, neighbors, etc.) or given infrequently.
Describe your cat’s appetite and eating habits.
What type of water does your cat drink?
Describe your cat’s thirst.
What is the usual color of your cat's urine? Does your cat mark/spray? Does your cat have excessive frequency of urinations or amount of urine? Straining, blood or mucus?
How often does your cat have a bowel movement? How often are they abnormal (soft or hard)? Color, odor and consistency of abnormal stools? Usual color, odor and consistency. Any straining blood or mucus?
Does your cat excessively lick genital or anal area? If so, please describe.
If eye discharge is present, describe side(s) affected, amount, frequency, thickness and color. Is it irritating to the patient/tissues?
If ear discharge is present, describe side(s) affected, amount, frequency, thickness and color. Is it irritating to the patient/tissues?
If skin eruptions are present, describe side(s) of the body and areas affected, amount, frequency, size and color. How irritating are they to the patient 0-10/10?
List all treatments your cat is currently receiving. What has been the response to each treatment?
Describe all exercise/activities your cat engages in, including frequency and duration.
Describe any significant emotional or behavioral patterns.
Does your cat get hot or cold easily?
Please indicate the severity of each issue below by clicking or sliding the bar right to indicate mild, moderate, or severe.
Sympathetic
Parasympathetic
Carbohydrate Metabolism, Sugar Handling
Circulation
Hepatic, Gall Blader
Digestive
Endocrine
Musculoskeletal (Calcium / Magnesium Metabolism)
Renal
Immune
Pain
For any issue marked on the form please answer the following: Is there any time of day or seasonal change? Is there anything that makes it better or worse?
Please list below the five main physical and or health complaints for this cat in order of importance.
This is a lengthy form and technical glitches can happen.

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If you experience a technical issue after completing this form, please send the PDF version to info@animalhealingarts.net.
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