Feline Health Questionnaire + Vaccine Risk Assessment

At which location does your pet have an appointment?*

Client Name*

First Last

Pet Name*

Health Questionnaire

Is your cat eating normally?*

Yes
No

If your cat has not been eating normally, what changes have you noticed?

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

Yes
No

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

Yes
No

If you have noticed any new lumps or bumps, where?

Does your cat drink or urinate more than usual?*

(Are you cleaning out the litter box more than usual recently?)

Yes
No

Does your cat urinate or defecate outside of the litter box?*

Yes
No

If your cat is urinating/defecating outside of the litter box, how often?

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

Yes
No

Does your cat’s breath have a bad odor?*

Yes
No

Do you do any form of at-home dental care?*

Yes
No

If you do provide at-home dental care, what do you use?

Does your cat throw up hairballs?*

Yes
No

Do you think your cat has any symptoms of arthritis?*

Yes
No

Does your cat cough or sneeze regularly?*

Yes
No

Has your cat has had fleas or ticks in the past?*

Yes
No

Do you give your cat heartworm prevention?*

Yes
No

What brand of heartworm prevention do you use?

Do you give heartworm products year-round?

Yes
No

Do you give your cat monthly flea/tick prevention?*

Yes
No

What brand of flea/tick prevention do you use?

Do you need to purchase any of these products today? (Check all that apply.)*

Flea/Tick - Yes!
Heartworm - Yes!
I do not need any products.

What kind (brand and type) of food do you feed your cat?*

Is your cat taking any medications other than heartworm/flea/tick prevention?*

Yes
No

If your cat is taking other medications, please explain.

Is your cat getting any supplements?*

Examples: CBD, fatty acids, joint supplements, vitamins, etc.

Yes
No

If your cat is getting supplements, please list.

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.

Is your cat spayed or neutered?*

Yes
No

If your cat is not spayed or neutered, please explain why.

Is your cat microchipped?*

Yes
No

Do you have any other concerns about your cat?

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?

Phone

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