Feline Health Questionnaire (Senior >10 years of age) X/TwitterThis field is for validation purposes and should be left unchanged.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. Does your cat seem to have the same energy and stamina as last year? Yes No 2. Have you noticed any changes in eating or drinking habits? NO Increased drinking Decreased drinking Excess hunger Decreased eating Picky eater Chewing on one side Dropping food Drooling 3. Have their litterbox habits changed at all? NO Increased urination Decreased urination Urination outside the litterbox Defecation outside the litterbox Diarrhea Constipation 4. Have you noticed any personality or behaviour changes in your cat? NO Excessive vocalization Slowing down or quieter Hide or isolate themselves Retract from touch Grouchier Lack of grooming Overgrooming (barber fur) 5. Does your cat exhibit any of the following: Weight loss Coughing or Labored Breathing Sneezing Vomiting Hairballs Scratching, Licking, or Hair loss Scooting New (or changing) Lumps or Bumps 6. Is your cat showing any of the following changes in mobility? NO Yes, Difficulty jumping/climbing UP Yes, Difficulty jumping/climbing DOWN Yes, Difficulty chasing moving objects Yes, Difficulty running 7. Does your cat have any difficult seeing, and/or hearing? NO Yes, vision loss Yes, hearing loss 8. What do you feed your cat? Please indicate brand of food, amounts, and how often for each of the following:Dry kibbleCanned foodTreats/other Add Remove9. What parasite preventive are you using for your cat? Nexgard Combo Advantage Profender Milbemax Other a. Last administered?10. Is your cat currently on ANY supplement or medication (incl. vitamins, probiotics, omegas, glucosamine, etc)? Yes No If yes, please indicate how often and amounts11. Does your cat have bad breath? Yes No 12. 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 13. 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 14. 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 15. 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?16. Is there anyone in contact with your cat who has an immunocompromised condition (ie, diabetes, pregnancy, cancer, children <5yrs, seniors >65yrs)? Yes No 17. Are there any health issues or behaviors you wish to discuss? Yes No If yes, please indicate:18. Does your cat have a microchip, or carry pet insurance? Yes No (# if known):Please indicate insurer: