Senior Wellness Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Preferred Pronouns (optional)
Cat's Name
*
Cat's Age
*
Cat's Gender
*
Spayed Female
Neutered Male
Female
Male
What would you like accomplished by the completion of this visit?
*
Does your cat go outside?
*
Yes
Yes but only under direct supervision.
No.
Have you applied or administered flea prevention in the past 30 days?
*
Yes.
No.
If Yes, please list name of product and when last used.
*
Do you need a refill of parasite prevention today?
*
Please be aware that our doctors recommend flea prevention for all cats, regardless of indoor only status. Although fleas can't live on humans, they can jump on us and use us as a vehicle to get in to your home. They can create itching, severe skin irritation in allergic cats, can pass tapeworms on to your cat, and even serve as a way of transmitting cat scratch fever to humans. Would you like to further discuss flea prevention at your appointment?
*
Yes
No
My cat currently eats (please select all that apply):
*
Dry food.
Wet food.
Cat treats.
People food.
Please list name of dry food, frequency of feeding per day, and amount given daily.
*
Please list name of wet food, frequency of feeding per day, and amount given daily.
*
Please list name of treats, frequency of feeding per day, and amount given daily.
*
Please list type of people food, frequency of feeding per day, and amount given daily.
*
My cat's appetite has been:
*
Increased.
Decreased.
Normal.
My cat's weight has:
*
Increased.
Decreased.
Stayed the same.
Is your cat currently on any medication or supplements other than parasite prevention?
*
Yes.
No.
If yes, please list name of medication, amount you give (eg 1 tab or 1 ml), and frequency given.
*
Do you need any medication or supplement refills today?
*
Have you noticed any new lumps or bumps?
*
Yes
No
Have there been any changes in litterbox habits?
*
Yes
No
Dental Concerns (please select all that apply):
*
Bad breath.
Difficulty eating.
Pawing at mouth.
My cat has had previous dental work.
No dental concerns.
Drooling.
Other
Respiratory Concerns (please select all that apply):
*
Sneezing.
Coughing.
Difficulty breathing.
No respiratory concerns.
Other
Metabolic Functions (please select all that apply):
*
Vomiting.
Diarrhea.
Increased water consumption.
Increased urine output.
No metabolic concerns.
Other
Activity/Mobility (please select all that apply):
*
Difficulty jumping.
Walking stiffly.
Limping.
Decreased activity level.
Increased activity level.
No activity/mobility concerns.
Other
Skin/Coat (please select all that apply):
*
Dry skin.
Itchiness.
Hair loss.
Fleas.
Matting.
No skin/coat concerns.
Other
Behavioral Concerns (please select all that apply). Please note: Additional time is needed to thoroughly discuss behavioral concerns. Please call our office to see if we may need to reschedule your appointment.
*
House soiling.
Aggression towards other cats.
Aggression towards people.
Scratching undesirable surfaces.
No behavioral concerns.
Other
Please tell us more about any issues you selected above, or describe any other concerns you have about your cat.
Would you like your cat to have a nail trim at this visit? ($25 charge for this service)
*
Yes.
No.
Blood Pressure Screening - We recommend testing all cats 7 years of age or olderfor high blood pressure (hypertension). Just as in humans, high blood pressure may not show clinical signs until it causes significant, irreversible damage to the eyes (retinal detachment and/or detachment), brain (strokes), and heart (muscle thickening). Measuring blood pressures in cats is not as easy as in humans - we use a machine specially designed to measure blood pressure in animals with very small blood vessels. We only pay attention to the top value (systolic blood pressure) since other values cannot be obtained accurately. Hypertension can be easily treated in cats with daily medication. ($51 charge for this service)
*
Yes, perform this service.
No, do not perform this service.
Senior Wellness Blood Panel - This comprehensive blood panel tests for diabetes, kidney disease, liver health, thyroid balance, protein and electrolyte levels, and cardiac health. Abnormalities in any of these levels can help us diagnose disease processes early, before they start to affect your cat's health. Often instituting treatment at this stage can provide much improved quality and quantity of life than if the same disease is diagnosed at a later stage. ($218 charge for this service)
*
Yes, perform this service.
No, do not perform this service.
Urinalysis - Kidney and bladder issues are very common in older cats. Checking a urine sample for urine concentration, protein level, white and red blood cells, and bacteria can help us find these issues and allow us to keep your cat comfortable and healthier in their senior years. ($74.50 charge for this service)
*
Yes, perform this service.
No, do not perform this service.
Our doctors recommend an annual intestinal parasite screening to be sure your cat is healthy! Please bring in a fresh (within 12 hours of leaving your cat's body) fecal sample in a plastic bag or closed container. It is fine if it has kitty litter on it. We only need about a large grape-sized amount of stool. The cost to send out this test is $59. Thanks for being a great partner in your cat's care!
Yes I will try to bring in a sample!
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