Feline Health Questionnaire Form DateOwner’s NamePronouns (optional)AddressPostal CodePhone (home)(cell)(work)Email Emergency Contact (other than immediate family)PhonePet’s NameBreedColourSex Male Female Neutered Spayed Age or BirthdayALL NEW PETS SHOULD BRING or REQUEST MEDICAL RECORDS BE SENT TO INFO@LYNWOODANIMALHOSPITAL.COM1. Have you noticed any of the following: Lethargy Limping Bad breath Increased drinking or eating habits Decreased drinking or eating habits Changes in Urination Diarrhea Constipation Coughing or Labored Breathing Sneezing Vomiting Hairballs Scratching Licking Scooting New (or changing) Lumps or Bumps 2. What diet are you currently feeding your cat?Dry kibbleCanned foodTreats/other Add RemovePlease indicate brand of food, amounts, and how often for each of the following:3. What parasite preventive are you using for your cat? Nexgard Combo Advantage Profender Milbemax 3a. Last administered?4. Is your cat currently on ANY supplement or medication (incl. vitamins, probiotics, omegas, glucosamine, etc)? Yes No If yes, please indicate how often and amounts5. What type of dental care do you provide for your cat? None Brushing daily/every other day Brushing other Dental diet Dental treats Dental at the groomers Water additive Other 6. Does your cat do any of the following: Boarding Go to the groomers Travel with You Have contact with other animals Go outside on a leash Go outside in an enclosed location (e.g., Catio) Free to roam outside unsupervised 7. Do you have other pets? Yes No If yes, how many and what species?If applicable, are they currently vaccinated and on parasite preventive? Yes No 8. What type of litter does your cat use?How often do you clean your cat’s litterbox?How many do you have, and where are they located?9. Is there anyone in contact with your cat who has an immunocompromised condition (ie, diabetes, pregnancy, cancer, children <5yrs, elderly >65yrs)? Yes No 10. Are there any health issues or behaviors you wish to discuss? Yes No If yes, please indicate:11. Does your cat have a microchip, or carry pet insurance? NO Microchipped Insured (# if known):Please indicate insurer:NameThis field is for validation purposes and should be left unchanged.