Feline Health History Form
Fairfax Campus
Primary Owner Name:
*
First Name
Last Name
Email:
*
example@example.com
Patient Name:
*
Patient Date of Birth:
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-
Month
-
Day
Year
Date
Patient Sex:
*
Male, Intact
Male, Castrated
Female, Intact
Female, Spayed
Patient Breed:
*
Patient Weight (in pounds/lbs):
*
Patient Weight (in kilograms/kg):
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This field has been automatically calculated based on the Patient's weight in pounds/lbs.
At which location are you requesting an appointment?
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Fairfax, VA Campus
Richmond, VA Campus
Primary (general practice) veterinary clinic:
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Primary veterinary clinic phone number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary veterinary clinic email address:
*
ABWC will request your pet's medical history using this address.
Veterinarian name (if you see a particular doctor):
First Name
Last Name
Date of last veterinary visit:
*
-
Month
-
Day
Year
Is your cat’s rabies vaccine up-to-date?
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Yes
No
Rabies vaccine date administered:
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Rabies vaccine location administered (name of hospital or clinic):
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Duration of rabies vaccine administered:
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1 year
3 years
Rabies vaccine due date:
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Due date is reflected on your pet's current rabies certificate.
Please provide details of why your cat's rabies vaccination is not current:
*
Indicate any specialty veterinarian services your cat has received (other than your primary care provider):
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Behavior
Cardiology
Internal Medicine
Neurology
Dematology
Ophthalmology
Orthopaedic
Oncology
Rehabilitation
None
Other
Name and phone number of specialty practice:
Name and phone number of specialty practice:
Name and phone number of specialty practice:
Please list ALL of the medications your cat currently takes:
*
Rows
Name of medication
Route of administration (oral/topical)
Dose (mg or mL)
Frequency administered
Cat's response to the medication
Heartworm prevention
Flea/tick prevention
Other
Other
Other
Other
Other
Other
Other
Has your cat taken any OTC behavior products or prescription medications in the past that have been discontinued due to an adverse response or lack of responsiveness?
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Yes
No
Please list ALL of the OTC behavior products or prescription medications your cat has taken in the past:
*
Rows
Name
dose (if known)
Cat's response to the medication
product/medication
product/medication
product/medication
product/medication
Any changes in eating or drinking within the last year?
*
Yes
No
Please explain the changes:
*
Has your cat presented with any of the following in the past year? Please check all that apply.
Coughing
Sneezing
Vomiting
Diarrhea
Lumps
Bumps
Pain
Limping
None of the above
Other
If you marked any of the above, please explain:
*
Has your cat ever had a seizure?
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Yes
No
Has your cat had kittens?
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Yes
No
How would you describe your cat's energy level?
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Very Low - Doesn't like walks or playtime. Sleeps a lot. May be affectionate or not.
Low - Has episodes of play and goes on short walks, but sleeps a lot otherwise.
Moderate - Enjoys walks, distinct sleep-wake times throughout the day, will play if engaged.
Moderate-High - Requires at least (1) 45 minute walk/play session per day. Only takes short naps
High - Needs multiple runs per day, high play drive, struggles to sleep during the day.
Any other thoughts regarding your cat's energy level, personality, and engagement throughout the day?
What brand and type of food do you feed this cat?
*
Please include dry and canned, if applicable.
What percentage of protein (per dry matter basis) is contained in the cat's food? (dry food only)
*
See food packaging or online reference for percentage.
This diet is:
*
Grain-inclusive
Grain free
How much do you feed per meal?
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How many meals are fed per day?
*
If you add any supplements to your cat's food, please list them here:
If your cat has any food allergies or sensitivities, please list them here:
Describe your cat's appetite:
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Good
Poor
How would you describe your cat's appetite for typical pet treats?
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Never eats pet treats.
Very picky about treats, but will slowly eat one.
May take it, then drop it, then eat it.
A little picky with treats. Gets excited and eats them politely.
Likes all treats. Gets excited, but is polite about taking them.
Eats anything. Snatches treats, may bite hand in the process.
How would you describe your cat's appetite for people food?
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Never interested.
Very picky, but will reliably eat a couple things.
A little picky - may need to be hand fed.
Likes some people food - mostly cheeses, meats, some crunchy fruits/vegetables.
Loves people food! Will only refuse a few specific foods.
Loves people food! Will snatch and steal anything/everything.
Has your cat ever eaten any other brands or types of food? Describe response to behavior and GI health.
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Please check ALL that apply regarding your cat's licking behavior.
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No excessive licking.
Chews or licks furniture, carpet, bedding, etc.
Chews or licks doors, walls, laminate, hardwood, etc.
Excessively licks people
Excessively licks self
Please check ALL that apply regarding your cat's non-food item chewing or consumption.
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Never eats non-food items.
Eats a small amount of grass periodically.
Eats grass frequently and can be redirected.
Eats grass frequently and is difficult to redirect.
Has an intense fixation for eating grass, difficult to redirect.
Eats other animals' feces.
Eats other cats' feces.
Eats their own feces.
Consumes small parts of their toys.
Consumes large chunks of their toys.
Consumes found/stolen objects.
Please provide any additional details or comments regarding your cat's eating, chewing, licking, or other oral habits.
Does your cat ever experience abdominal heaving that results in vomiting?
*
Yes
No
If yes to vomiting, please check all that apply:
*
Occurs every day.
Occurs 3-4 times per week.
Occurs 1-2 times per week.
Occurs 4-5 times throughout the month.
Vomiting occurs, but is very rare.
Vomitus contains only bilious (yellow) or clear fluid.
Vomitus contains small amounts of undigested food.
Vomitus contains large quantities of undigested food.
Vomitus contains non-food items.
Does your cat ever experience spitting up that does NOT involve abdominal heaving (regurgitation)?
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Yes
No
If yes to regurgitation, please check all that apply:
*
Occurs every day.
Occurs 3-4 times per week.
Occurs 1-2 times per week.
Occurs 4-5 times throughout the month.
Regurgitation occurs, but is very rare.
Vomitus contains only bilious (yellow) or clear fluid.
Vomitus contains small amounts of undigested food.
Vomitus contains non-food items.
Vomitus contains large quantities of undigested food.
Does your cat experience other upper GI symptoms? Please check all that apply.
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None
Episodes of increased frequency of swallowing.
Episodes of swallowing hard, but not increased frequency.
Gagging without any vomit production.
Excessive lip licking.
Drooling
Lip smacking
Excessive burping
Please provide any other details regarding your cat's upper GI symptoms:
Does your cat experience soft stools or diarrhea?
*
Yes
No
If yes, please check all that apply:
*
Occurs every day.
Occurs 3-4 times per week.
Occurs 1-2 times per week.
Occurs 4-5 times throughout the month.
Occurs 3-5 times per year.
Occurs, but is very rare.
Can be accompanied by vomiting.
Can identify a specific cause (ex: dietary indiscretion)
Requires veterinary treatment to resolve.
Episodes accompanied by bright red blood.
Episodes accompanied by dark red blood.
Episodes accompanied by mucous.
Episodes occur with increased urgency and frequency to defecate.
Using the above as a guide, what percentage of the time do you see the following fecal scores?
*
Rows
1
2
3
4
5
6
7
Percentage
Check ALL items that pertain to your cat's defecation ritual:
*
Uses the litter box consistently for defecation.
Refuses to use the litter box for defecation.
Mostly uses the litter box for defecation, but will occasionally defecate just outside the box.
Mostly uses the litter box for defecation, but will occasionally defecate far away from the box.
Some combination of the above.
They sniff and move litter around for a couple seconds before posturing to defecate.
Walks slowly or “freezes” as they prepare to defecate.
Their behavior is very frenetic or frantic before or after defecating.
They get “distracted” from defecating easily.
They vocalize while defecating.
When done defecating, they race out of the litter box (or away from the location).
When done defecating, they turn around and smell their excrement.
When done defecating, the cover or attempt to cover the feces with litter.
They remain agitated for an extended period after defecating.
Does your cat demonstrate excessive flatulence?
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Yes
No
Sometimes
Does your cat demonstrate excessive burping?
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Yes
No
Sometimes
Does your cat demonstrate excessive belly sounds?
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Yes
No
Sometimes
Please provide any other details about your cat's lower GI symptoms:
Is your cat showing signs of: (please check all that apply)
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Slowing down
Limping
Slow to rise from lying down
Difficulty jumping up (onto furniture or your lap)
Feeling stiff
Difficulty going up and down stairs
Difficulty chasing objects/toys
Difficulty running
None of the above
Has your cat ever been diagnosed with pain or arthritis?
*
Yes
No
Has your cat ever been prescribed pain medication? (ex. gabapentin, Rimadyl, Previcox, Metacam, Galliprant, etc.)
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Yes
No
I don't know
Why was it prescribed?
*
Does your cat bury his/her urine after eliminating?
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Yes
No
Has your cat been diagnosed and treated for urinary tract infections in the past?
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Yes
No
When was the last time your cat had a urinalysis preformed by your veterinarian?
*
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