Feline Health History Form - Richmond Campus

Primary Owner Name:

First NameLast Name

Email:

example@example.com

Patient Name:

Patient Date of Birth:

Date

Patient Sex:

Patient Breed:

Patient Weight (in pounds/lbs):

At which location are you requesting an appointment?

Primary (general practice) veterinary clinic:

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 NameLast Name

Date of last veterinary visit:

Indicate any specialty veterinarian services your cat has received:

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?

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?

Please explain the changes:

Has your cat presented with any of the following in the past year? Please check all that apply.

If you marked any of the above, please explain:

Has your cat ever had a seizure?

Has your cat had kittens?

How would you describe your cat's energy level?

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:

What is the amount and frequency you feed?

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:

How would you describe your cat's appetite for typical pet treats?

How would you describe your cat's appetite for people food?

Has your cat ever eaten any other brands or types of food? Describe response to behavior and GI health.

Please check ALL that apply regarding your cat's licking behavior.

Please check ALL that apply regarding your cat's non-food item chewing or consumption.

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?

If yes to vomiting, please check all that apply:

Does your cat ever experience spitting up that does NOT involve abdominal heaving (regurgitation)?

If yes to regurgitation, please check all that apply:

Does your cat experience other upper GI symptoms? Please check all that apply.

Please provide any other details regarding your cat's upper GI symptoms:

Does your cat experience soft stools or diarrhea?

If yes, please check all that apply:

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:

Does your cat demonstrate excessive flatulence?

Does your cat demonstrate excessive burping?

Does your cat demonstrate excessive belly sounds?

Please provide any other details about your cat's lower GI symptoms:

Is your cat showing signs of: (please check all that apply)

Has your cat ever been diagnosed with pain or arthritis?

Has your cat ever been prescribed pain medication? (ex. gabapentin, Rimadyl, Previcox, Metacam, Galliprant, etc.)

Why was it prescribed?

Does your cat bury his/her urine after eliminating?

Has your cat been diagnosed and treated for urinary tract infections in the past?

When was the last time your cat had a urinalysis preformed by your veterinarian?