Feline Annual Health Survey Owner Name* First Last Cat's nameAgeHome PhoneWork Phone: (include extension)Email Cell phone # to text to:Name of Pet Health Insurance: None Insurance Nameinsurance nameAre you interested in learning about an affordable monthly-pay preventative care option with additional cost-saving benefits?YesNoIf 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?YesNoHas your cat ever had a vaccine reaction?YesNoDid you have any problems getting your cat in the carrier today?YesNoPlease rate your cat's current level of pain:None1234Diet: My cat eats (Mark all that apply) Dry food Canned or semi-moist food Treats People foodBrand of food my pet eatsType of people food my pet eatsMy Cat: (Mark all that apply) Is a picky eater Will only eat canned food Is always begging for food Will only eat dry food Will eat most types of cat foodMy 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 outsideMy 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 householdHow many cats are in your household including this cat?If there are other cats in your household, do they go/sneak outside?YesNoIs your pet currently having problems with: Fleas Ticks NeitherAre there children, expectant mothers or immunocompromised people exposed to your pet?YesNoIs your pet on monthly parasite preventative? (If Yes, what brand?)YesNoIf yes, what brandLast 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 patiosWhich best describes your pet’s mouth? Great Some calculus (tartar) Some calculus (tartar) and red gums Really bad odor I never lookPlease check any conditions that apply to your pet: Vomiting Limping Behavioral changes Itchy skin Destructive Difficulty Jumping Hearing problems Skin lumps and bumps Decreased Appetite Clawing Vision problems Coughing or sneezing Incontinence Underweight Scratching Frequent urination Constipation Seizures Overweight Biting Diarrhea Litter box problems Increased thirst Decreased grooming AggressionComparative 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)1151368224147232815764321680536178464118887451992849209695321100105722104116123108126424111 Please write your pet’s “human age Age Scale: Adult SeniorSuper SeniorClient SignatureDate
