Please print this form,
fill it out and bring it with you to your appointment.
| YES | NO | (CHECK (" ")
WHERE APPROPRIATE OR WRITE IN ANSWER) |
| q | q | Sneezing: For how long?____________ How often? (#/hrs or #/days) __________________ |
| q | q | Nose Discharge: q Right q Left q Both nostrils |
| q | q | Coughing: For how long? ____________ How often? (#/hrs or #/days)______________ |
| q | q | Runny Eyes: For how long? ________________q Right q Left q Both eyes |
| q | q | Vomiting: For how long? ______________________Frequency per day _______________ q Food q Hair q Fluid (color: ) q Grass |
| q | q | Diarrhea: For how long? _____________ q Liquid q Soft q Blood q Mucus q Hair q Gas q Foreign Material (type:______________ ) q Straining -Frequency per day____ |
| q | q | Abnormal Urinations:
For how long? ______________ q
Blood in urine q
Straining to urinate Are the stools in the litterbox? q Yes q No Urinating in unusual places? Where____________ |
| q | q | Weight loss: How Much? _____________For How Long? ________________ |
| q | q | Change in Food
Consumption: q
Increased q
Decreased q
Not eating at all for days. Type & brand of food your cat eats ______________________________ |
| q | q | Increased Water Intake: For how long? ___________q A little increase q A large increase |
| q | q | Depressed/listless: For how long? ______________________ |
| q | q | Limping: For how
long? ___________________Which leg? q
Right front q
Left front q Right rear q Left rear |
| q | q | Wounds/lumps: Location ______________________________________ |
USE REVERSE SIDE OF PAGE FOR ADDITIONAL HISTORY