Name of owner_________________________________________
Address of Owner_______________________________________
______________________________________
Home Phone: _________Work Phone: _________Cell: _________
Acceptable hours to call/how late or early_____________________
When was last visit to veterinarian__________Vaccine History___
Permission to Obtain Records? Y/N (circle)
Microchipped? Y/N (circle)
Past illness/ injury_______________________________________
_____________________________________________________
Strictly indoors, mainly indoors, indoor/outdoor, outdoor?(circle)
Other cats in household?________________________________
Flea control method?___________ History of tapeworms? Y/N
Diet including treats/scraps_______________________________
Is weight a concern? __________
Hairball preventative used?_______________________________
Water consumption from dish, sink, other locations?____________
Uses scratching posts appropriately? If no, please request form
Any behavioral concerns?________________________________
Any concerns regarding: (please circle)
Skin
Eyes Drinking excessive water
Ears Urinating excessively
Teeth/Mouth Eating unusual items
Diarrhea Decreased energy level
Constipation Decreased appetite
Coughing Increased appetite
Difficulty breathing Scratching Furniture
Blood in urine Defecating outside litter box
Straining to urinate Urinating outside litter box
Any other concerns?_____________________________
Reason for today’s visit? ________________________