Pre-Exam Questionnaire

Please complete and return this form BEFORE coming to the hospital. This will help ensure your doctor is able to focus on and address all of your concerns. You will able to give more details to the doctor in person during the appointment. Please note that we need a separate form for each patient being seen.

Owner's Name*

First and last

Cat's Name*

Last name only if different from above

Appointment Date*

Date your appointment is scheduled, not the date you're filling this out

Briefly describe the reason your pet is being examined today and questions you would like addressed*

List what you are feeding your cat (names/brands) and how much they are eating per meal*

List what flea/tick control you are using and when the last dose was applied*

List all medications including the dose and when they were last given (date/time) and include any over the counter supplements*

Has your pet had any coughing / sneezing / eye or nasal discharge you would like to discuss?*

YesNo

List concern:

Has your pet had any vomiting / diarrhea / or change in stools you would like to discuss?*

YesNo

List concern:

Has your pet been drinking more or less and/or urinating more or less?*

YesNo

List concern:

Has there been in change with your pet's mobility such as how they jump up or go down steps?*

YesNo

If yes, please describe

Have you noticed any lumps or masses?*

YesNo

If yes, please note where it is located, how long it has been present, and if you have noticed it growing.