Cat MEDICAL History Form
Cat’s Name:______; Owner’s Name:______; Date:______
Besides completing this Pet MEDICAL HISTORY Review, if your pet has not been seen here before then please also fill out the brief “Welcome to Cats Only Veterinary Clinic" New Client Registration Form. (all of this paperwork really does help). Thank you!
(Please circle/check/answer all that apply):
1. I have seen "worms" in my Cat's stool recently? Yes (); No (); (flat? round?);
Please describe: ”rice”/”sesame seeds”/”inch worms”; (how long? In inches?______).
2. My Cat has had diarrhea recently? Yes (); No (); (a) the consistency of "water", or “pudding”, or “jello”? & color?______; (b) how often?______; and, for how long? (days/weeks/hours?)______.
3. My Cat has been vomiting recently? Yes ( ); No ( ); (a) looks like?______; (b) how often?______; (c) for how long? (days/weeks/hours?)______
4. My Cat scratches/bites/chews itself excessively? Yes ( ); No ( ); where on body? (ears/
Rump/tail/paws/neck/other)______.
5. My Cat is not eating properly? True ( ); False ( ); (a) eats a “little” ( ); eats nothing at all ( ); or (c) has not eaten anything since 9pm last night ( ).
6. My Cat drinks water (a) normally ( ); or (b) less than normal ( ); or (c) more than normal ( ); or (d) nothing or (e) nothing since 9pm last night ( ).
7. My Cat has been coughing/sneezing? Yes ( ); No ( ); (a) how often?______; (b) for how long? (days/weeks/hours)______.
8. My Cat seems to have difficulty urinating and/or defecating? Yes ( ); No ( ); please describe______.
9. My Cat has had previous surgery? Yes ( ); No ( ); (a) Spayed? ( ); (b) Neutered? ( );
(c) Other?______; Approx. when?______.
10. My female Cat was last in estrus (“Heat”) when?______.
11. My Cat has never been tested for Feline Leukemia Virus? Yes ( ); No ( ); Result?______
11. My Cat is taking/recently taken the following medications?______.
12. Also, the Doctor needs to know that:______.
***13. Please telephone me with an estimate if my total FEES exceed $______.
***14. The Doctor can reach me at the following Telephone Number:______.
***Please do not omit items #13. & 14. Thank you 11-29-2016