FELINE RISK ASSESSMENT FORM



Animal Medical of Chesapeake921 N. Battlefield Blvd. * Chesapeake, VA 23320In order for us to provide your feline family member with the best care possible, please take a moment to answer the following questions regarding his/her healthcare needs.Your Name: __________________________Cat’s Name: _____________________ Date: ________Has your address or contact number/info changed since your last visit: Yes No If yes, please provide updated info:Phone: 1st:___________________2nd:______________Address: ____________________________________________________________Other contact info: ___________________________________________________Risk Assessment:1. Where does your cat spend its time?Goes outside: [ ] once a month [ ] once a day [ ] once a weekWhen outside, he/she is: [ ] roaming free [ ] on a porch/deck [ ] on a leash[ ] Indoor 100% (NEVER goes outside)2. What are you currently feeding your cat?[ ] Dry Brand _________________________ Amount: _____ cups per day [ ] free choice[ ] Canned Brand ______________________ Amount: _____ cups/day [ ] free choice[ ] Semi-moist Brand ___________________ Amount: _____ cups/day [ ] free choice[ ] Other_________________________________________________________________________3. What do you think about your cat’s weight?[ ] very thin [ ] a little underweight [ ] ideal [ ] a little overweight [ ] obese4. Is your cat on any supplements or medications (other than what we’ve prescribed)? Yes No If yes, list:________________________________________5. Is your cat on monthly heartworm prevention? Yes No If yes, list:____________________________6. If your cat on a monthly flea/tick flea/tick preventative? (if yes, what__________________) No 7. Have you noticed any of the following: (please check all that apply)[ ] drinks more than usual [ ] urinating/defecating outside litter box[ ] fleas or ticks on your cat [ ] panting, heavy breathing or coughing[ ] lumps/bumps on your cat’s body [ ] bad breath, drooling or reluctance to eat[ ] activity level (lays around more/less active) [ ] vomiting (explain)_________________________[ ] diarrhea (explain)___________________________________________________________________8. Do you ever have mice or bats get into the house? Yes No 9. Do you have other cats/dogs that go outside? Yes No 10. Do you ever take your cat: [ ] to a boarding facility [ ] to another household with cats/dogs11. Are you interested in more information about pet health insurance? Yes No 12. Any other concerns that you have, or any changes since your last visit?__________________________________________________________________________________________________________________________________________________________________________13. Senior Cats Only: Have you noticed any change in your pet’s mental state such as:( □ No ) increased confusion decreased social interactionchange in sleep patterns aimless wandering dribbling urine in sleep: other______________________Date_______________________________(FELINE RISK ASSESSMENT FORM.doc) ................
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