Medical History Questionnaire

Save time during your next appointment! Fill out the form below as thoroughly as possible.

Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Appointment Date *

If you have prior veterinary clinic records, or records from recent consultant/ER facilities that you can share with us, please share them here.

Click or drag files to this area to upload. You can upload up to 10 files.

Would you like an estimate provided to you before we begin any treatment? *

If you know if any past medical issues that you would like to share, please detail them here. *

Have you noticed or have concerns about any of the following? *

	No	Yes	Unsure
Sneezing or Coughing?	NoSneezing or Coughing? No	YesSneezing or Coughing? Yes	UnsureSneezing or Coughing? Unsure
Vomiting (including scarf and barf)?	NoVomiting (including scarf and barf)? No	YesVomiting (including scarf and barf)? Yes	UnsureVomiting (including scarf and barf)? Unsure
Hairballs?	NoHairballs? No	YesHairballs? Yes	UnsureHairballs? Unsure
Inappropriate urination? Going outside the litterbox?	NoInappropriate urination? Going outside the litterbox? No	YesInappropriate urination? Going outside the litterbox? Yes	UnsureInappropriate urination? Going outside the litterbox? Unsure
Diarrhea or irregular stool?	NoDiarrhea or irregular stool? No	YesDiarrhea or irregular stool? Yes	UnsureDiarrhea or irregular stool? Unsure
Eating or drinking more/less?	NoEating or drinking more/less? No	YesEating or drinking more/less? Yes	UnsureEating or drinking more/less? Unsure
Drooling, dropping food or changes in appetite?	NoDrooling, dropping food or changes in appetite? No	YesDrooling, dropping food or changes in appetite? Yes	UnsureDrooling, dropping food or changes in appetite? Unsure
Lower or higher energy than usual?	NoLower or higher energy than usual? No	YesLower or higher energy than usual? Yes	UnsureLower or higher energy than usual? Unsure
Watery or irritated eyes?	NoWatery or irritated eyes? No	YesWatery or irritated eyes? Yes	UnsureWatery or irritated eyes? Unsure
Head shaking or ear concerns?	NoHead shaking or ear concerns? No	YesHead shaking or ear concerns? Yes	UnsureHead shaking or ear concerns? Unsure
Itching or hair loss?	NoItching or hair loss? No	YesItching or hair loss? Yes	UnsureItching or hair loss? Unsure
Arthritis or joint pain?	NoArthritis or joint pain? No	YesArthritis or joint pain? Yes	UnsureArthritis or joint pain? Unsure
Behavior changes? Changes in energy?	NoBehavior changes? Changes in energy? No	YesBehavior changes? Changes in energy? Yes	UnsureBehavior changes? Changes in energy? Unsure
Lumps/Masses/Growths?	NoLumps/Masses/Growths? No	YesLumps/Masses/Growths? Yes	UnsureLumps/Masses/Growths? Unsure

Please share any specifics or observations about the above history: ie when you first noticed these symptoms, or what you are observing.

Diet: What are we eating, and approximately how much: *

you The Please

Please tell us about any current medications or supplements that your cat is taking:

Is your cat currently on any flea and tick preventatives? *

Yes, consistently.
Yes, occasionally but not all year round.
No

Does your cat go outside? *

Yes
No
Confined to deck or cattio

Are you aware of any allergies or vaccine reactions that you can share with us? *

Allergies: What allergies or vaccine reactions has your cat experienced? *

We will let you know if your cat is due for any vaccines, but if you already know what vaccinations you would like update, please make your selections. A current rabies vaccine is required by Washington State Law. If your cat is not well enough to receive vaccines, we will recommend returning in the future once they feel better.

	No	Yes	Unsure
Rabies 1 year vaccine	NoRabies 1 year vaccine No	YesRabies 1 year vaccine Yes	UnsureRabies 1 year vaccine Unsure
Rabies 3 year vaccine	NoRabies 3 year vaccine No	YesRabies 3 year vaccine Yes	UnsureRabies 3 year vaccine Unsure
FVRCP vaccine	NoFVRCP vaccine No	YesFVRCP vaccine Yes	UnsureFVRCP vaccine Unsure
FeLV vaccine *A test should confirm a negative result before vaccination.	NoFeLV vaccine *A test should confirm a negative result before vaccination. No	YesFeLV vaccine *A test should confirm a negative result before vaccination. Yes	UnsureFeLV vaccine *A test should confirm a negative result before vaccination. Unsure

No matter what age a cat may be, lab work gives us a huge advantage. The sooner we detect abnormalities, the sooner we can begin treatment before a major medical issue occurs. Are you interested in including any of the following preventative diagnostics during your visit?

	No	Yes	Unsure
Annual Bloodwork (Checks blood cell health and organ health.)	NoAnnual Bloodwork (Checks blood cell health and organ health.) No	YesAnnual Bloodwork (Checks blood cell health and organ health.) Yes	UnsureAnnual Bloodwork (Checks blood cell health and organ health.) Unsure
Senior Bloodwork (Additionally includes thyroid testing)	NoSenior Bloodwork (Additionally includes thyroid testing) No	YesSenior Bloodwork (Additionally includes thyroid testing) Yes	UnsureSenior Bloodwork (Additionally includes thyroid testing) Unsure
Urine Analysis	NoUrine Analysis No	YesUrine Analysis Yes	UnsureUrine Analysis Unsure
Fecal testing (Internal parasites)	NoFecal testing (Internal parasites) No	YesFecal testing (Internal parasites) Yes	UnsureFecal testing (Internal parasites) Unsure
FIV/FeLV Snap Test (results in 5-10 minutes)	NoFIV/FeLV Snap Test (results in 5-10 minutes) No	YesFIV/FeLV Snap Test (results in 5-10 minutes) Yes	UnsureFIV/FeLV Snap Test (results in 5-10 minutes) Unsure
X-ray Screening (For cancer, bone/tissue health and internal organ health )	NoX-ray Screening (For cancer, bone/tissue health and internal organ health ) No	YesX-ray Screening (For cancer, bone/tissue health and internal organ health ) Yes	UnsureX-ray Screening (For cancer, bone/tissue health and internal organ health ) Unsure
Allergy testing	NoAllergy testing No	YesAllergy testing Yes	UnsureAllergy testing Unsure

Are there any additional concerns that you would like the doctor to address today?

While your pet is here with us today, would you like us to update: *

	No	Yes
Nail Trim	NoNail Trim No	YesNail Trim Yes
Refill Medication	NoRefill Medication No	YesRefill Medication Yes
Get a written prescription to take to an outside pharmacy	NoGet a written prescription to take to an outside pharmacy No	YesGet a written prescription to take to an outside pharmacy Yes

Medication(s) to Refill

In additional to picking up medications directly from the clinic, we can also authorize medications, food and supplements through our online pharmacy. Check out https://catcareclinic.ourvet.com/pet/ to place an order today.

Written prescriptions to go:

If you would like to use an outside pharmacy for your pet’s written prescriptions, the doctors of Cat Care Clinic will happily provide you with a written prescription that you can use at any in-person or internet pharmacy of your choosing. Photocopies are often not accepted, so please do not forget to retrieve this before you go.

Consent for Treatment:

I authorize the veterinarians of Cat Care Clinic (and their designated assistants) to perform examinations on, prescribe medications for, and treat the above-named cat as therapeutically and/or diagnostically indicated. *

I have read and understand.

I acknowledge that all pre- and post-treatment care is my responsibility. I also certify that no guarantee or assurance has been made as to the results that may be obtained. *

I have read and understand.

I am the owner of the above-named cat and/or have the authority to execute this consent. I certify that I have read and fully understand this consent form. Furthermore, I assume financial responsibility for all charges incurred to the patient, and understand that payment is due at the completion of the appointment. *

I have read and understand.

Signature *

Clear Signature

Medical History Questionnaire

Consent for Treatment:

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