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(954) 920-2400 | 521 N Federal Hwy, Hollywood, FL 33020

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Feline History Form

Owner*
Date*
Date Format: MM slash DD slash YYYY
Pet Name*
Breed*
Color
Age
Sex*
- Male
- Male (Neutered)
- Female
- Female (Spayed)
About Your Cat
Your cat was obtained from*
- Breeder
- Pet store
- Friend
- Stray
- Humane Soc.
Your cat is*
- Indoor
- Outdoor - free roaming
- Both
Number of cats in household*
Brand of pet food*
Canned/Dry
- Canned
- Dry
How is your cat's appetite*
- Normal
How is your cat's attitude*
- Happy-Active-Normal
- Depressed-Lethargic
Is your cat drinking*
- Normally
- More
- Less than usual.
Do you notice any of the following
- Limping
- Eye Discharge
- Nasal discharge
- Sneezing
- Coughing
- Shaking head
- Scooting
- Scratching
- Vomiting
- Diarrhea
- Lumps
- Bad breath often
- Weight loss
- Lethargy / weakness
- Seizures
- Hair loss
Your cat uses the litter box
- Consistently
- Usually
- Digs and covers in the litter box
- Urinating outside litter box
- Defecating outside litter box
Do you notice straining, crying out or pain when using the litter box
- Yes
- No
- Sometimes
Your Cat's Medical History
Previous veterinary hospital:
May we request your records from their office?*
- Yes
- No
- First visit to a veterinarian
Has your cat had the following in the last 12 months:
Physical examination*
- Yes
- No
- Unsure
Date of last exam*
Dental examination and cleaning*
- Yes
- No
- Unsure
Date of last exam*
Feline Leukemia Virus test*
- Yes
- No
- Unsure
Date of last exam*
Feline Immunosuppressive Virus test*
- Yes
- No
- Unsure
Date of last exam*
Fecal sample test*
- Yes
- No
- Unsure
Date of last exam*
Blood testing for thyroid, kidney & liver function*
- Yes
- No
- Unsure
Date of last exam*
Rabies*
- Yes
- No
- Unsure
Date of last vaccination*
Feline Distemper*
- Yes
- No
- Unsure
Date of last vaccination*
Feline Leukemia*
- Yes
- No
- Unsure
Date of last vaccination*
Has your cat been dewormed in the last 12 months*
- Yes
- No
- Unsure
Date*
Flea & tick preventative(s)
Are you familiar with geriatric care for cats over 7 years of age
- Yes
- No
Are you familair with feline heartworm disease
- Yes
- No
Current medications and allergies
Comments

The Animal Medical Center & Bird Clinic of Hollywood

Phone: (954) 920-2400 Address: 521 N Federal Hwy, Hollywood, FL 33020

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