New Patient Information and Medical History Sheet

Transcription

1 New Patient Information and Medical History Sheet PATIENT INFORMATION: Name Age/Date of Birth Species Feline Male/Female Breed Intact/Neutered Color/Markings Clawed/Declawed Temperament Indoor/Outdoor/Both Rabies Tag # /State Microchip # DIET: Please list current and past diets: Type (wet/dry/raw) (x day, 2x day, etc) Name/Brand How Long on This Diet? DIETARY SUPPLEMENTS: Please list all treats, vitamins, probiotics, etc: (x day, 2x day, etc) Name/Brand MEDICATIONS: Please list all medications your cat receives: Name of Drug Dose Given Route Given Reason Given

2 Is your cat allergic to any medications? If yes, please note drug and type of reaction: MEDICAL PROBLEMS: Please list any medical problems/disorders your cat has or has had: Name of Illness or Injury Date of Onset End Date SURGERIES: Please list any surgery your cat has had (apart from routine desexing): Type of Surgery Date Reason/Outcome CURRENT HEALTH: Is your cat currently doing anything that may indicate illness? If yes, please describe (including date of onset, frequency and severity): Does your cat show any of the following? Activity Vomiting Hairballs Appetite increase Appetite decrease Diarrhea Constipation Energy increase Energy decrease Start Date 2

3 Activity Thirst increase Thirst decrease Coughing Sneezing Urination volume increase Urination volume decrease Urination frequency increase Urinating out of the box Defecating out of the box Scooting Scratching Start Date If so, what body parts? Hair Loss Scabs or redness Lumps or bumps Bad breath Difficulty chewing Weight loss Weight gain Difficulty jumping up Difficulty jumping down Pain when touched Ear problems Eye problems Behavior problems 3

4 Please describe any other problem(s) not listed above: HOUSEHOLD AND LIFESTYLE: Do you have any other pets in the household? If so, please list, including species, age, and relationship with this cat: Does your cat go outside at all? Do you (or someone in your home) travel often? Do you ever board your cat or hire a sitter? (free roam, yard only, outside enclosure, on leash, etc) Have you done Environmental Enrichment for your cat? Are there any situations in your home that might stress your cat? If yes or unsure, please describe: : : If so, how does your cat handle being boarded or taken care of? Have you taken your cat to a veterinary clinic or hospital? If so, how did your cat handle the transportation and the vet visit? 4

5 Has your cat ever had to take medicine? If so, please describe the medication (i.e.: oral tablets, oral liquid, eyedrops, injections, etc.), and how your cat tolerated (or tolerates) the process of being medicated: Please describe your cat s personality: Has your cat ever lived anywhere other than Colorado? If so, please list all locations: Where did you acquire this cat? Shelter/Rescue org Breeder Pet Store Other If other, please describe: IMMUNITY / VACCINATIONS: Has your cat been tested for immunity (antibody titer) to any of the following? TEST Feline Distemper 2 Feline Rhinotracheitis Feline Calicivirus3 Rabies 2 3 Date Panleukopenia the P in FVRCP The FVR in FVRCP The C in FVRCP. These three are commonly administered as a single combination vaccine. 5 Result

6 Has your cat received any vaccination for the following? VACCINE Rabies Feline Distemper Feline Rhinotracheitis2 Feline Calicivirus3 Feline Leukemia Virus (FeLV) Feline Immunodeficiency Virus (FIV) Other vaccines of any kind (please describe): Date of Last Vaccination YR 3YR Additional immunity questions: Has your cat ever received an adjuvanted vaccine product? Has your cat ever experienced any adverse vaccine reactions? If so, when? Please describe the nature of the reaction: Has your cat received another dose of the same vaccine since? If so, how did that go? Has your cat ever tested POSITIVE for any of the following? Feline Leukemia Virus (FeLV) Feline Immunodeficiency Virus (FIV) Heartworms Print name: Home phone: Signature: Date: 6