Puppy / Kitten Questionnaire Date MM slash DD slash YYYY Owner’s Name:Pronouns (optional)Address Street Address 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 Home NumberCell NumberWork NumberWhich of the above numbers do you prefer as primary contact number?Email Emergency Contact (other than immediate family):Phone NumberPet’s Name:Breed:Colour:Sex Male Female Neutered Spayed Age / Birthday ALL NEW PETS SHOULD BRING or REQUEST MEDICAL RECORDS BE SENT TO INFO@LYNWOODANIMALHOSPITAL.COM 1. 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?Please indicate brand of food, amounts, and how often for each of the following:Dry kibbleCanned foodTreats/other Add Remove3. What parasite preventive are you using for your cat? Nexgard combo Advantage Profender Milbemax Other OtherLast 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 amounts.Supplement / MedicationHow often?Amount Add Remove5. 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 (please indicate) Others(Required)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 (eg, Catio) Free to roam outside unsupervised 7. 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 8. What type of litter does your cat use?a. How often do you clean your cat’s litterbox?b. 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, seniors >65yrs)? Yes No 10. Are there any health issues or behaviors you wish to discuss? Yes No a. If yes, please indicate:11. Does your cat have a microchip, or carry pet insurance? Yes No Microchipped (# if known):Insured (please indicate insurer):