Medical Exam Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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.
Is your cat up to date on flea prevention?
*
Yes.
No.
If Yes, please list name of product and when last used.
*
Do you need a refill of parasite prevention today?
*
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?
*
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 that you would like addressed at this visit (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.
Submit
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