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?* Yes No If so, what medications? Does your cat go outside at all?* Yes No Is 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?* Yes No Have you noticed an increase in your cat's appetite?* Yes No Does your cat vomit or have hairballs more than once every 2 weeks?* Yes No Has your cat's feces changed in firmness or frequency of elimination?* Yes No Have you noticed your cat drinking more water than normal?* Yes No Have you noticed more urine in the litter box?* Yes No Has your cat had any sneezing or ocular or nasal discharge in the past month?* Yes No Has your cat had any coughing?* Yes No Have you noticed any changes in behavior such as more irritable, sleeping in new places, etc?* Yes No Have you noticed any increase in vocalization?* Yes No Is your cat grooming more than normal and/or having areas of hair loss?* Yes No Does your cat seem less active than before or sleeping more than usual?* Yes No Does your cat jump up normally?* Yes No Does your cat jump down normally?* Yes No Does your cat climb up stairs or steps normally?* Yes No Does your cat climb down stairs or steps normally?* Yes No Does your cat run normally?* Yes No Does your cat chase moving objects (toys, prey, etc.)?* Yes No Other concerns or comments?NameThis field is for validation purposes and should be left unchanged.
