Feline Health Questionnaire (Kitten <1 year of age) DateOwner’s NamePronouns (optional)Address Street Address Address Line 2 City Province/Region Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (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. When did you obtain your kitten, and how old were they?2. Where did you obtain your kitten? Private Pet store Breeder Shelter/rescue Other 3. Has your kitten received any vaccinations, or dewormers? Please bring documentation. Yes No If known, indicate which vaccine(s) and date(s) givenIf known, indicate which dewormer(s) and date(s) given4. 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 Lumps or Bumps 5. Did your kitten’s diet change when you brought them home? Yes No 6. 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:7. Is your kitten currently on ANY supplement or medication (incl. vitamins, probiotics, etc)? Yes No If yes, please indicate how often and amountsSupplement/MedicationHow often?Amount Add Remove8. Will your kitten be doing 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 9. Do you have other pets? Yes No If yes, how many and what species?SpeciesHow many? Add RemoveIf applicable, are they currently vaccinated and on parasite preventive? Yes No 10. 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?11. Is there anyone in contact with your cat who has an immunocompromised condition (ie, diabetes, pregnancy, cancer, children <5yrs, seniors >65yrs)? Yes No 12. Are there any health issues or behaviors you wish to discuss? Yes No If yes, please indicate:13. Does your kitten have a microchip, or carry pet insurance? Yes No (# if known):Please indicate insurer:EmailThis field is for validation purposes and should be left unchanged.