Exam Questions Form - Cheshire Cat Feline Health Center - San Diego, CA

Cheshire Cat Feline Health Center

4680 Clairemont Mesa Blvd.
San Diego, CA 92117

(858)483-1573

www.cheshirecatclinic.com

Exam Questionnaire

If you already have an appointment please fill out this form, if you do not have an appointment please call to make one at 858-483-1573.

Exam Questions Form

Name
First Name
Last Name
Phone
Phone TypePhone Number
What is your cat's name?

What is the reason for your visit?

How is your cat doing overall?

Any changes in mobility?

Is you cat Indoor, Outdoor or Both?

How many pets are in your household?

What food do you feed your cat? (brand, amount, frequency, dry, canned)

Is your cat eating normal amounts of food?

Do you think your cat is losing weight?

Is your cat drinking excessive water?

Is your cat vomiting? If yes, please describe the frequency and appearance

Is your cat having diarrhea? If yes, please describe the frequency and apperance

Any Sneezing or Coughing? If so please describe

Any changes in behavior?

Is your cat using the litter box regularly?

Is your cat urinating and defecating normally? If not please explain

Any other issues or concerns?

Please list any medications you are currently giving (name,strength, amount and how often)

Are you giving your cat any other supplements, remedies, etc?

Is your cat on flea control? If so which kind and the last time applied

Has your cat been tested for FELV or FIV if so please indicate if tested negative or positive

Does your cat have a microchip?

If we need to send home any medications, would you prefer Liquid or Pills?


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