Ervets4pets.com - Feline Medical History Form

Feline Medical History Form
Patient/Owner Information
Patient Name*
Date

MonthDayYear
Date
Owner name
About Your Cat
How long have you had your cat?*
Where did you get your cat (breeder, pet store, rescue, stray, friend, other)?*
Does your cat go outside?*

YesNo
How much time does your cat spend outside?*
Number and kind of pets in the household*
Diet (brand, canned/dry, amount, frequency of feeding)*
List types and amounts of treats or table food*
Has your cat recently traveled out of the area?*

YesNo
If so, when and where?*
Your Cat’s Medical History
Who is your cat’s primary care veterinarian?*
When was the last time your cat was seen at a veterinarian?*
Has your cat been vaccinated in the past 12 months?*
Does your cat have any prior health concerns or conditions?*
Has your cat had recent blood work?*

YesNo
Was it normal?*

YesNo
Please list the abnormalities
Is your cat on heart worm prevention?*

YesNo
If so, what kind and frequency?
Is your cat on flea/tick prevention?*

YesNo
If so, what kind and frequency?
Does your cat have any known allergies?*

YesNo
If so, describe*
Is your pet being seen for Vomiting and/or Diarrhea?*

YesNo
Is your cat on any medications*

YesNo
Please list all current medications (name, amount, and frequency) and dosing schedule*
Presenting Complaint
What is going on?
When did it start?*
When was the last time your cat was normal?*
How is your cat’s appetite*

NormalIncreasedDecreasedAnorexic
How is your cat’s attitude?*

Happy active-normalDepressed lethargicOther
How is your cat’s water intake?*

NormalIncreasedDecreasedOther
Have you seen any of the following symptoms?*

Nasal DischargeSneezingEye DischargeLethargyStraining to UrinateStraining to DefecateVomitingDiarrheaCoughingLimpingHair LossSkin Masses/LumpsScratchingWeight LossSeizuresWeakness/CollapseParalysisVocalizingShaking headScootingIncreased Rate or Effort with BreathingNoneOther
Does your pet appear to be in pain?*

YesNo
Additional Comments*
Should be Empty:

Feline Medical History Form

Patient/Owner Information

About Your Cat

Your Cat’s Medical History

Presenting Complaint