Feline Health Questionnaire Form Owner’s Name Date Address Postal Code Phone numbers (home) (cell) (work) Email Emerg. Contact(other than immediate family): ph: Pet’s Name Breed Colour Sex Male Female Neutered Spayed Age or Birthday What brand of food do you feed your cat? How much do you feed? Where does your cat sleep? What parasite preventive are you using? Last administered? What type of dental care do you provide for your cat? Do you have other pets? YES NO Please list name, breed, and sex of other petsAre they currently vaccinated and on hea rtworm and pa rasite preventive? YES NO Does your cat enjoy going outside? When was your cat’s last dental cleaning under general anaesthesia? Does your cat: Board Groom Travel with You Have contact with other animals Have you noticed any lumps or bumps on your cat? YES NO Have you noticed any of the following: Hacking or Labored Breathing Limping Lethargy Diarrhea Increased Thirst Increased Urination Vomiting Constipation Dry, Lusterless Fur Sneezing or Panting Are there any health issues or behaviors you wish to discuss? YES NO Are there any behaviors you wish you could change? YES NO If yes, please describeIs your pet currently on ANY medication (incl. A spirin, glucosamine, etc)? YES NO If yes, frequency and amounts that are given PhoneThis field is for validation purposes and should be left unchanged.
