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Pre-Exam History Questionnaire
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*
" indicates required fields
Your Name
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First
Last
Phone
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Email
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Pet’s Name
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General Questions
Summary of any concerns for your pet today
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List the brand and flavor of any canned food you are feeding
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List the amount of canned food you feed over a 24 hr period
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List the brand and flavor of any dry foods you are feeding
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List the amount of dry food you feed over a 24 hr period
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List any treats your cat gets each day
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Is your cat on any medication? Please list the medication name, how much you are giving and the frequency for each drug or supplement
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Do you need any refills today?
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Yes
No
If so, what medications?
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Does your cat go outside at all?
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Yes
No
Is your cat on any heartworm or flea preventative and if so which one and when was the last dose given?
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Medical questions
Have you noticed a decrease in your cat's appetite?
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Yes
No
Have you noticed an increase in your cat's appetite?
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Yes
No
Does your cat vomit or have hairballs more than once every 2 weeks?
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Yes
No
Has your cat's feces changed in firmness or frequency of elimination?
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Yes
No
Have you noticed your cat drinking more water than normal?
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Yes
No
Have you noticed more urine in the litter box?
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Yes
No
Has your cat had any sneezing or ocular or nasal discharge in the past month?
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Yes
No
Has your cat had any coughing?
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Yes
No
Have you noticed any changes in behavior such as more irritable, sleeping in new places, etc?
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Yes
No
Have you noticed any increase in vocalization?
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Yes
No
Is your cat grooming more than normal and/or having areas of hair loss?
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Yes
No
Does your cat seem less active than before or sleeping more than usual?
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Yes
No
Does your cat jump up normally?
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Yes
No
Does your cat jump down normally?
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Yes
No
Does your cat climb up stairs or steps normally?
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Yes
No
Does your cat climb down stairs or steps normally?
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Yes
No
Does your cat run normally?
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Yes
No
Does your cat chase moving objects (toys, prey, etc.)?
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Yes
No
Other concerns or comments?
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What is your favorite thing about your cat?
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