Cat's Name Owner's Name* Date MM slash DD slash YYYY Email* Habitat Indoor only In & out freely Outdoor w/o supervision Outdoor w/ supervision My other cats go outside Appetite Very good Good Erratic Picky Poor Very poor Change in appetite Up Down No change Food(s) Diet Eats specific meals Fed free choice Table food Treats Dog food % table food % treats % dog food Water Consumption Does not drink excessively Drinks very excessively Amount up Amount down Urination Normal amount More than normal amount Less than normal amount Activity level Very active Normal Very inactive More active Less active Do you board your cat? Yes No Does your cat go to cat shows? Yes No Lameness Yes No Which leg(s) Length/Time Constant Intermittent Duration Behavior Yes No Any notable change? Vomiting Yes No If yes, how often? What is vomited? Is there a relationship to eating? Yes No How? Diarrhea Yes No Time/Length Occasionally Frequently Frequency If diarrhea is present, Number of bowel movements per day: Straining to defecate: Yes No Coughing Yes No Time/Length Occasionally Frequently Sneezing Yes No Time/Length Occasionally Frequently Nasal discharge Yes No Type Pus Watery Bloody Duration Itching Yes No Type Seasonal Year-round Location(s) on the cat’s body History of fight wounds Yes No How many in the last 2 years Has tested positive for Feline Leukemia Virus Feline AIDS Virus If yes, how long ago? Fleas or ticks noted recently Yes No On heartworm preventative? No Irregularly Regularly Number of months per year On flea preventative? No Irregularly Regularly Number of months per year Name of heartworm/flea preventative Revolution Advantage Multi Interceptor Medications regularly taken Summary of your concerns Has your address or phone number or e-mail address changed since last year?New information Where and when can we reach you today?Phone*Times Phone*Times PhoneThis field is for validation purposes and should be left unchanged.