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Feline Medical History Form

Owner Name

Pet Name

Has your pet ever had a reaction to vaccines?

Yes

No

Have you seen your pet passing any worms?

Yes

No

Has your pet had an illness/injury since the last visit?

Yes

No

Has your pet ever had a history of seizures, or have they had one recently?

Yes

No

Does your pet get table scraps?

Yes

No

Does your pet ever strain to urinate?

Yes

No

Has there been any recent vomiting?

Yes

No

Has your pet been coughing, sneezing, gagging?

Yes

No

Any lethargy?

Yes

No

Any lameness, weakness, or stiffness?

Yes

No

Shaking of the head, scratching or hair loss?

Yes

No

Scooting of rear?

Yes

No

New unusual lumps or bumps?

Yes

No

Bad breath?

Yes

No

Diarrhea or Constipation?

Yes

No

Behavioral Changes?

Yes

No

Is your pet allergic to any food or medication?

Yes

No

Is any member of your family allergic to peanut butter, turkey or beef?

Yes

No

Is your cat showing difficulty climbing up or down stairs?

Yes

No

Is your cat showing difficulty chasing moving object?

Yes

No

Is your cat showing difficulty jumping up or down?

Yes

No

Is your cat showing difficulty running?

Yes

No

Is your cat Energetic & Enthusiastic?

Less

Normal

More

Is your cat Happy & Content?

Less

Normal

More

Is your cat Active & Comfortable?

Less

Normal

More

Is your cat Drinking?

Increased?

Decreased?

Same?

Is your cat Appetite?

Increased?

Decreased?

Same?

Is your cat Urination?

Increased?

Decreased?

Same?

Is your cat Defecation?

Increased?

Decreased?

Same?

Current food?

Current medication?

Refills needed?

Yes

No

Date