Feline Annual Health Survey in Dunedin, FL

Owner Name*

First Last

Cat's name

Age

Home Phone

Work Phone: (include extension)

Email

Cell phone # to text to:

Name of Pet Health Insurance:

None
Insurance Name

insurance name

Are you interested in learning about an affordable monthly-pay preventative care option with additional cost-saving benefits?

Yes
No

If your cat is receiving a vaccination by injection today, please read this paragraph and sign below:
A small number of cats develop a non-painful lump under the skin after they are vaccinated. The vast majority of these lumps disappear spontaneously without treatment. However, on rare occasions (approximately 1 to 10 in 100,000 cats), a potentially serious growth can arise in the area of the vaccination. Should you notice a lump in the area of a vaccination at any time, please do not hesitate to bring your pet in for a no charge examination. Your peace of mind is very important to us. Please feel free to discuss this or anything else that you think may affect the health or happiness of your pet with our practice team.

Is your cat the best cat in the whole world?

Yes
No

Has your cat ever had a vaccine reaction?

Yes
No

Did you have any problems getting your cat in the carrier today?

Yes
No

Please rate your cat's current level of pain:

Diet: My cat eats (Mark all that apply)

Dry food
Canned or semi-moist food
Treats
People food

Brand of food my pet eats

Type of people food my pet eats

My Cat: (Mark all that apply)

My Cat (mark the choice that applies best to your cat):

Is always inside and never sneaks outside
Is mostly inside, but occasionally goes/sneaks outside
Goes inside and outside
Is always outside

My Cat (mark the choice that applies best to your cat):

Never comes in contact with other cats
Only comes in contact with the cats in our household
May come in contact with cats other than in our household

How many cats are in your household including this cat?

If there are other cats in your household, do they go/sneak outside?

Yes
No

Is your pet currently having problems with:

Fleas
Ticks
Neither

Are there children, expectant mothers or immunocompromised people exposed to your pet?

Yes
No

Is your pet on monthly parasite preventative? (If Yes, what brand?)

Yes
No

If yes, what brand

Last date given

Roughly how many doses of parasite prevention have you given your cat in the last 12 months?

Did you know? Approximately 65% of cats (even indoor cats) can become infected with heartworms, which are transmitted by mosquitoes. My Cat:

Probably is bitten by mosquitoes
Is never bitten by mosquitoes
Could occasionally be bitten by mosquitoes when they get in our home, porch or patios

Which best describes your pet’s mouth?

Please check any conditions that apply to your pet:

Comparative Ages of Cats and Humans: This table will help you determine if your pet is senior or super senior by showing your cat’s relative age in human years. Please write your pet’s “human age"

Cat Age (Years)	Human Age (Years)	Cat Age (Years)	Human Age (Years)
1	15	13	68
2	24	14	72
3	28	15	76
4	32	16	80
5	36	17	84
6	41	18	88
7	45	19	92
8	49	20	96
9	53	21	100
10	57	22	104
11	61	23	108
12	64	24	111

Please write your pet’s “human age

Age Scale: Adult SeniorSuper Senior

Client Signature

Date