Name Cat's Name Age Sex Spayed/Neutered? Yes No Is your cat currently on heartworm preventative? Yes No Not Sure If yes, date of last dose: Is your Cat currently using flea/tick prevention? Yes No Not Sure If yes, date of last dose: What brand of food do you feed your cat? Food Type Dry food/kibble Wet food Both wet and dry food Home-cooked Is your cat on any medications or supplements? If so, please list here: How often do you feed your cat? Once per day Twice per day (In the morning and evening) Free feed (food is available at all times) Do you feed your cat treats? Yes No Type and Frequency of Treats Does your cat (check all that apply)… Go outside Sit on a deck or patio Sit by an open window Sleep in the bed with you or other family members Play with other pets Play with children Board at a facility when you are out of town Behavior/Neurologic My cat is just not acting like himself/herself My cat interacts less with the family My cat seems confused or disoriented My cat has been meowing or whimpering for no apparent reason My cat’s sleeping patterns have changed My cat has had tremors or episodes of shaking My cat has displayed circling, head tilts, or repetitive movements Other If other, please explain Body Function My cat has bad breath and red or swollen gums My cat has difficulty chewing My cat’s eating habits have changed My cat has gained weight My cat has lost weight My cat is drinking more water than usual My cat is urinating more frequently than usual My cat’s bowel habits have changed (increased frequency, diarrhea, constipation, straining) My cat vomits more than occasionally My cat seems to have trouble seeing or hearing Other If other, please explain Heart/Lungs My cat has difficulty jumping to the couch/bed I have noticed a change in my cat’s activity level My cat seems to be limping and/or seems stiff and has difficulty rising from a resting position My cat has been unusually quiet My cat has been vocalizing more than normal Other If other, please explain Heart/Lungs My cat seems to be panting more My cat has been coughing or sneezing My cat tires more rapidly or seems short of breath Other If other, please explain Skin/Coat I have noticed changes in my cat’s grooming habits My cat scratches, licks, and chews excessively My cat has changes in coat/skin, or has new lumps or bumps My cats’s skin has an odor Other If other, please explain Δ
