New Patient Questionnaire s2

New Patient Questionnaire (Feline) Pet’s Name ______Date ______Tech ______

Question Answer 1. Does your pet have any nicknames that you use? 2. How long have you had your pet: 3. What percentage of time does your pet spend outdoors? 4. What do you currently feed you pet? Brand Name? 5. Do you board you pet? If so, how frequently?  Yes  No Frequency: 6. Do you have your pet groomed or bathed  Yes  No Frequency / Location: outside of your home. If so, how frequently? Does your pet shed a lot? 7. Has your pet ever been hospitalized? If so,  Yes  No Explain: how long ago and for what condition(s)? 8. Does your pet have any other health  Yes  No Explain: problems? If so, specify. 9. Has your pet had any routine blood test other  Yes  No Explain: than heartworm, Feline Leukemia or Feline Immunodeficiency Virus within the last two years? If so, what and when? 10. Do you provide any home dental care?  Yes  No Type / Frequency: 11. Do you use a flea preventive? If so, what type?  Yes  No Type / Frequency: 12. Is your pet on any other medications, including  Yes  No Type / Frequency: aspirin or nutritional supplements? 13. Has your cat been tested for Feline Leukemia  Yes  No Explain: and/or Feline Immunodeficiency Virus? 14. Is your cat on heartworm prevention?  Yes  No Type: 15. Has your cat been vaccinated against Feline  Yes  No Explain: Infectious Peritonitis? 16. Do you use a hairball removal agent such as  Yes  No Type / Frequency: laxatone? If so, what and how often? 17. Does your cat have any behavior problems  Yes  No Explain: that you wish you could correct? 18. Any other issues you want us to address with your pet? If you need additional room for your answers please use the back of this form.