Pet Information Form
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1Pet’s Full Name __________________________________________________ Age _____________ Breed _________________
Home Phone _______________________ Address _____________________________________________________________
Email Address ______________________________________________________________________________________________
□ Female Intact
□ Female Spayed
□ Male Intact
□ Male Neutered
Please review the information above and make any corrections needed, then answer the questions below.
□ Yes □ No
□ Yes □ No
Does your cat have health insurance?
Is your cat microchipped?
Is your cat the best cat in the whole world? □ Yes □ No
Diet
My Cat Eats (mark all that apply):
My Cat (mark all that apply):
□ Dry food (brand)_________________________________________
□ Will only eat canned food
□ Will only eat dry food
□ Canned or Semi-Moist Food (brand)_________________________
□ Is always begging for food
□ Is a picky eater
□ Treats (brand)___________________________________________
□ Will eat most types of cat food
□ People food (type) _______________________________________
Lifestyle (This helps us determine risk for parasites, viruses and other infectious diseases)
My Cat (mark the choice that applies best to your cat):
My Cat (mark the choice that applies best to your cat):
□ Is always inside and never sneaks outside
□ Never comes in contact with other cats
□ Is mostly inside, but occasionally goes/sneaks outside
□ Only comes in contact with the cats in our household
□ Goes inside and outside
□ May come in contact with cats other than in our household
□ Is always outside
If your cat is receiving a vaccination by injection
How many cats are in your household including this cat? ______________
today, please read this paragraph and sign
If there are other cats in your household, do they go/sneak outside? □ Yes □ No
below:
A small number of cats develop a non-painful
lump under the skin after they are vaccinated. The vast
Parasites
majority of these lumps disappear spontaneously without
Have you seen either of these on your pet within the last year?
treatment. However, on rare occasions (approximately 1
□ Fleas □ Ticks □ Neither
to 10 in 100,000 cats), a potentially serious growth can
arise in the area of the vaccination. Should you notice a
Approximately 65% of cats can become infected with heartworms,
lump in the area of a vaccination at any time, please do
which are transmitted by mosquitoes.
not hesitate to bring your pet in for a no charge
examination. Your peace of mind is very important to us.
My Cat (mark the choice that best applies to your cat):
Please feel free to discuss this or anything else that you
□ Probably is bitten by mosquitoes □ Could occasionally be bitten by mosquitoes
think may affect the health or happiness of your pet with
□ Is never bitten by mosquitoes
when they get in our home, porch or patio
our practice team.
Are there children, expectant mothers or immunocompromised people exposed to your pet?
Yes
No
Is your pet on monthly parasite preventative?
Yes Brand ______________________ Last date given __________________
No
Health Problems
Which best describes your pet’s mouth?
□ Great
□ Some calculus (tartar)
□ Some calculus (tartar) and red gums
□ Really bad odor
□ I never look
Please mark the conditions that apply to your pet: □ Normal (no problems)
□ Vomiting
□ Limping
□ Behavioral changes
□ Itchy skin
□ Difficulty jumping
□ Hearing problems
□ Skin lumps and bumps
□ Decreased appetite
□ Vision problems
□ Coughing or sneezing
□ Incontinence
□ Underweight
□ Frequent urination
□ Constipation
□ Seizures
□ Overweight
□ Diarrhea
□ Litter box problems
□ Increased thirst
□ Decreased grooming
Comparative Ages of Cats and Humans: This table will help you determine if your pet is senior or super senior
by showing your cat’s relative age in human years. Please circle your pet’s “human age”
Adult
.Cat Age (Years)
Human Age (Years)
Cat Age (Years)
Human Age (Years)
Age Scale:
Senior
1
15
13
68
Super Senior
2
24
14
72
3
28
15
76
Thank you for helping us keep your cat healthy!
4
32
16
80
5
36
17
84
X_________________________________
6
41
18
88
Client Signature
7
45
19
92
8
49
20
96
9
53
21
100
Date ______/_____/______
10
57
22
104
11
61
23
108
12
64
24
111
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