Pre-visit Survey For Medical Issues
Urinary Problems
Cat’s Name
*
Your Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Please tell us about your cat’s diet.
*
Please tell us about any treats, dental chews, and human food your cat receives.
*
Please tell us about any other prescription, OTC medications, &/or supplements your pet is taking, including current dose and frequency.
The following are relevant to my pet? (Mark all that apply)
*
Changes in environment
Changes in housemates
Changes in schedule
None
Other
Please explain the changes in the here:
Are they having accidents in the house?
*
Yes
No
Are there changes in the frequency of urination in your pet?
*
Yes
No
Not sure
If YES, please explain the changes:
Can your pet urinate normally?
*
Yes
No
Not sure
If NO, please explain the changes:
When your pet urinates, is it a steady stream?
*
Yes
No
Not sure
Is there constant dribbling?
*
Yes
No
Not sure
I’ve noticed the following changes in my pet’s urine (Mark all that apply):
*
Odor
Appearance
Amount
None
Other
Please explain the changes
Has their thirst increased or decreased?
*
Increased
Decreased
Stayed the same
Are they having normal bowel movements? Both in frequency and appearance?
*
Yes
No
If NO, please explain
How are your pet’s activity levels?
*
Higher than Normal
Lower than Normal
The Same
How long have these changes been going on or when did you first notice a problem?
*
If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.
Vomiting/Diarrhea
Is your pet vomiting?
*
Yes
No
How often is your pet vomiting?
*
Are they having normal bowel movements? Both in frequency and appearance?
*
Yes
No
If NO, please explain
How often is your pet having diarrhea?
*
What is the consistency?
*
How are your pet’s activity levels?
*
Higher than Normal
Lower than Normal
The Same
Is your pet still trying to eat?
*
Yes
No
Did your pet receive (Mark all that apply):
*
Any human foods
Get new/abnormal treats
Take any medications not prescribed for them
Chew on household items
Get into the trash
Get into anything in the yard
Are any other pets in the household showing similar symptoms?
*
Yes
No
Has your pet been to the dog park, boarding, or been exposed to pets that are not in the household?
*
Yes
No
How long have these changes been going on or when did you first notice a problem?
*
If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.
Skin Rashes & Itchiness
Which flea & tick prevention is your cat receiving?
*
Bravecto
Revolution
Credelio
Cheristin
None
Other
When was your cat’s last dose given?
*
Does your pet seem itchy?
*
Yes
No
Is your pet shaking his/her head?
*
Yes
No
When was the problem first noted?
*
Where on the body was the problem first noted?
*
Are any other pets at home experiencing similar problems?
*
Yes
No
Have you been treating with anything at home, including shampoos, ointments, oral medications or other OTC medications?
*
If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.
Lumps & Skin Growths
If you have noticed multiple lumps, please answer the questions about all the lumps.
When did you first notice the lump?
Has it grown?
Does the pet bother it?
Has it changed in texture or appearance?
If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.
Other Medical Problem
Please tell us about any treats, dental chews, and human food your cat receives.
Please tell us about any other prescription, OTC medications, &/or supplements your cat is taking, including current dose and frequency.
The following are relevant to my pet? (Mark all that apply)
*
Changes in environment
Changes in housemates
Changes in schedule
None
Other
Please explain the changes
Please describe concerns you that would like to discuss with the doctor during your visit.
*
Submit
Should be Empty: