Pre- Examination History Checklist Owner's NameCat's NameAgePhoneEmail Please select any of the following that your cat may be experiencing. If your cat is not experiencing a symptom listed, please leave it blank.Weight GainMildModerateSevereStarted When?Weight LossMildModerateSevereStarted When?Decreased AppetiteMildModerateSevereStarted When?Increased AppetiteMildModerateSevereStarted When?Won't eat normal diet anymore but acts hungryMildModerateSevereStarted When?VomitingMildModerateSevereStarted When?DiarrheaMildModerateSevereStarted When?Constipation / Straining to defecateMildModerateSevereStarted When?Increased water consumptionMildModerateSevereStarted When?Increased urinationMildModerateSevereStarted When?Lumps / Masses on the skinMildModerateSevereStarted When?Skin Lesions, Hair loss, ScabsMildModerateSevereStarted When?Bad breath / Difficulty chewingMildModerateSevereStarted When?Decreased awareness - gets confused or disorientedMildModerateSevereStarted When?Behavioral changes - sleeping in different places, hiding under the bed, etc.MildModerateSevereStarted When?Increased affection or more clingy than normalMildModerateSevereStarted When?Chewing, licking, eating non-food itemsMildModerateSevereStarted When?Describe:Increased irritability or aggression w/ people or animalsMildModerateSevereStarted When?Increased fear or anxietyMildModerateSevereStarted When?Decreased tolerance to being heldMildModerateSevereStarted When?Overgrooming / Decreased groomingMildModerateSevereStarted When?Muscle tremors / shakingMildModerateSevereStarted When?Coughing / SneezingMildModerateSevereStarted When?Excessive vocalizing at nightMildModerateSevereStarted When?Excessive vocalizing during the dayMildModerateSevereStarted When?Decreased activity, sleeping more than normalMildModerateSevereStarted When?Waking owners at nightMildModerateSevereStarted When?Has difficulty jumping up or down off furnitureMildModerateSevereStarted When?Bunny hops when going down stairsMildModerateSevereStarted When?Other problems or concerns:DietDoes your cat go outside at all?CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
