Pre- Examination History Checklist Your Name:* First Last Pet’s Name*General Questions:Summary of any concerns for your pet today:*List the brand and flavor of any canned food you are feeding:*List the amount of canned food you feed over a 24 hr period:*List the brand and flavor of any dry foods you are feeding:*List the amount of dry food you feed over a 24 hr period:*List any treats your cat gets each day:*Is your cat on any medication? Please list the medication name, how much you are giving and the frequency for each drug or supplement*Do you need any refills today?*YesNoIf so, what medications?Does your cat go outside at all?*YesNoIs your cat on any heartworm or flea preventative and if so which one and when was the last dose given?Medical questionsHave you noticed a decrease in your cat's appetite?*YesNoHave you noticed an increase in your cat's appetite?*YesNoDoes your cat vomit or have hairballs more than once every 2 weeks?*YesNoHas your cat's feces changed in firmness or frequency of elimination?*YesNoHave you noticed your cat drinking more water than normal?*YesNoHave you noticed more urine in the litter box?*YesNoHas your cat had any sneezing or ocular or nasal discharge in the past month?*YesNoHas your cat had any coughing?*YesNoHave you noticed any changes in behavior such as more irritable, sleeping in new places, etc?*YesNoHave you noticed any increase in vocalization?*YesNoIs your cat grooming more than normal and/or having areas of hair loss?*YesNoDoes your cat seem less active than before or sleeping more than usual?*YesNoDoes your cat jump up normally?*YesNoDoes your cat jump down normally?*YesNoDoes your cat climb up stairs or steps normally?*YesNoDoes your cat climb down stairs or steps normally?*YesNoDoes your cat run normally?*YesNoDoes your cat chase moving objects (toys, prey, etc.)?*YesNoOther concerns or comments?NameThis field is for validation purposes and should be left unchanged.
