Date of visit:
Appointment time:
Your name:
Your cat's name:
Your cat's breed/sex:
Your cat's birthdate:
List any medications, including flea and heartworm preventative, that your cat is currently taking.
Describe your cat's diet. Please include the brand name, any treats/table scraps, amount of food given, and how frequently your cat is fed.
Please list any other comments/questions that you may have.
Wanders aimlessly: (yes or no)
Appears lost or confused: (yes or no)
Gets "stuck" in corners, behind furniture: (yes or no)
Stares into space or at walls: (yes or no)
Tremors or shakes: (yes or no)
Difficulty finding the door: (yes or no)
No longer responds to verbal cues or name: (yes or no)
Appears to forget reason to go to litter box: (yes or no)
Solicits attention less: (yes or no)
Less likely to stand/lie for petting (walks away): (yes or no)
Less enthusiasm upon greeting: (yes or no)
No longer greets owners: (yes or no)
Urinates/defecates out of litter box (in view of owner): (yes or no)
Sleeps more (overall) in 24 hours: (yes or no)
Sleeps less during the night: (yes or no)
Decrease in purposeful activity: (yes or no)
Difficulty in climbing the stairs: (yes or no)
Difficulty jumping up: (yes or no)
Increased stiffness or limping: (yes or no)
Slow to get up after sleeping/lying down: (yes or no)
Urinates indoors: (yes or no, if yes please indicate number of times per week)
Defecates indoors: (yes or no, if yes please indicate number of times per week
Indicates pain on urination/defecation: (yes or no)
Increased thirst: (yes or no)
Increased urination: (yes or no)
Increased frequency of bowel movements: (yes or no)
Change in appetite: (yes or no)
Vomiting/diarrhea: (yes or no)
Coughing: (yes or no)
Trouble seeing: (yes or no)
Loss of hearing: (yes or no)
Bad breath: (yes or no)
Panting: (yes or no)
Skin and/or haircoat changes: (yes or no)
Weight change: (yes or no)
Additional comments: