Feline Health Questionnaire + Vaccine Risk Assessment

At which location does your pet have an appointment?*

Client Name*

First Last

Pet Name*

Health Questionnaire

Any changes in your cat’s drinking or urination? (Are you cleaning out the litter box more than usual?)*

Yes
No

If you have seen a change in your cat's drinking or urination, what changes have you noticed?

Has your cat’s weight or appetite changed in the last year?*

Yes
No

If your cat's weight or appetite have changed, what changes have you noticed?

Have you noticed any new lumps or bumps on your cat?*

Yes
No

If you have noticed any new lumps or bumps, where? Have they grown quickly?

Does your cat vomit or have diarrhea more than one time per week?*

Yes
No

Does your cat’s breath stink?*

Yes
No

Do you have any questions about at-home dental care?*

Yes
No

Does your cat have any of the following arthritis signs? (Check all that apply):

difficulty going up/down stairs
slipping on non-carpeted areas
obvious limping/lameness
slow to get up after laying down
difficulty jumping up or down
paws have been surgically declawed

If you have noticed any of these signs, are you interested in learning more about services or products that could help?*

Yes
No

Do you have any concerns about fleas or ticks?*

Yes
No

Have you noticed your cat coughing, sneezing, or open-mouth breathing?*

Yes
No

If your cat has been coughing, sneezing, or open-mouth breathing, please explain:

Does your cat have any history of allergies?*

Examples: vaccines, food, medications, seasonal, etc.

Yes
No

If your cat has a history of allergies, please explain.

Do you have concerns about your cat’s behavior?*

Yes
No

If you do have concerns about your cat's behavior, please explain:

Do you have any major changes upcoming that could affect your cat?*

Yes
No

If you do have major changes upcoming, please explain:

Are you interested in a microchip for your cat today?*

Yes
No

Do you have any other concerns about your cat today?

Vaccine Risk Assessment

Help us learn more about your cat by checking all the following that apply:

My cat lives totally indoors and never goes outside of my home, not even on an enclosed porch (except to come to the veterinarian’s office).
My cat is indoors only except for when it sits on a screened-in porch or sits in our yard under our direct supervision.
My cat gets outside without direct human supervision and is therefore possibly exposed to other cats in the neighborhood.
My cat has been treated for a cat bite wound in the past.
My cat came from a pet store, humane society, rescue organization, or was a stray in the last year.
My cat goes to a groomer or boards in a kennel at least one time per year.

My cat has tested positive for one of the following diseases (check all that apply):

Feline Leukemia
Feline AIDS
Heartworm Disease

My cat has had an adverse reaction to vaccines in the past.*

Yes
No

When did your cat have a reaction to vaccines? What kind of adverse reaction(s) or symptom(s) did your cat show?

Email

This field is for validation purposes and should be left unchanged.

Feline Health Questionnaire + Vaccine Risk Assessment

Health Questionnaire

Vaccine Risk Assessment

After Hours Emergency Care

Services

More Links

City Way Animal Clinics