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: