Feline Medical History Form
Patient/Owner Information
Patient Name
*
Date
-
Month
-
Day
Year
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
Was it normal?
*
Yes
No
Please list the abnormalities
Is your cat on heart worm prevention?
*
Yes
No
If so, what kind and frequency?
Is your cat on flea/tick prevention?
*
Yes
No
If so, what kind and frequency?
Does your cat have any known allergies?
*
Yes
No
If so, describe
*
Is your pet being seen for Vomiting and/or Diarrhea?
*
Yes
No
Is your cat on any medications
*
Yes
No
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
*
Normal
Increased
Decreased
Anorexic
How is your cat’s attitude?
*
Happy active-normal
Depressed lethargic
Other
How is your cat’s water intake?
*
Normal
Increased
Decreased
Other
Have you seen any of the following symptoms?
*
Nasal Discharge
Sneezing
Eye Discharge
Lethargy
Straining to Urinate
Straining to Defecate
Vomiting
Diarrhea
Coughing
Limping
Hair Loss
Skin Masses/Lumps
Scratching
Weight Loss
Seizures
Weakness/Collapse
Paralysis
Vocalizing
Shaking head
Scooting
Increased Rate or Effort with Breathing
None
Other
Does your pet appear to be in pain?
*
Yes
No
Additional Comments
*
Submit
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