Cat History Questions Form Cat History Questionnaire Name * Name First First Last Last Patient's Name * Number for Dr. to contact during appointment * Email * Date of appointment * Time of appointment * AM PM Please be aware that we are providing the best possible care we can with the restrictions of Covid. Each appointment has a time slot and it is vital for the flow of your pet’s visit that we have the right contact number and that you answer the phone when the doctor calls. Being unable to contact you during your visit will lead to delays. Also please be aware that we have had an excessive number of appointments and emergencies and that we apologize for any delays during your visit. These questionnaires allow us to make sure we are answering all potential questions and providing a full comprehensive exam with Dr. Culpepper. What is the reason for your visit today? * Do you have an area of concern that you would like the doctor to address today? * Is your cat experiencing any of the following * Vomiting Diarrhea Sneezing Coughing Limping None of these Is your pet coping with any lifestyle changes since our last visit? * Yes No If yes, please explain Have you noticed any eating or drinking changes in your cat over the last 6 months? * Yes No If yes, please explain Has your pet’s elimination habits changed (urination, defecation) since their last visit. * Yes No In what way has it changed? * There's been no change Frequency House Soiling Urine Marking Change in Color Diarrhea Missing box Have you noticed any lumps, bumps, growths you want addressed today? * Yes No If yes, please state their location Have you noticed any change in your pets exercise tolerance? * Increased Decreased No Change Have you noticed any changes in your cat’s vision? Or any eye changes? * Yes No Have you noticed any odor or discharge in your pets ears? * Yes No Does your cat excessively shake head or scratch ears? * Yes No If you are human, leave this field blank. Next
