FELINE Senior Wellness Exam FELINE Senior Wellness Exam This form is designed to help our team gather important information about your pet's current status for your upcoming visit to our Fear Free clinic! Your pet's name:*Your name:*Last visit we gave you information on our health plans. Do you have any questions?* yes, sign me up! no, thanks I'm interested, but I have more questions! Where does your cat spend most of his/her day? Inside Outside In a room In a kennel With you How would you describe your cat's litter box training? Excellent Inappropriate How many litter boxes are set out, and where are they located in your home?*What type(s) and size(s) of litter boxes are you using (covered, uncovered, automatic, oval, large rectangular, etc.)?*Is your cat's litter scented or unscented? Scented Unscented Is your cat's litter clay or clumping? Clay Clumping Have you noticed any changes in activity, such as being more active at night, or sleeping more during the day? No change Reduced Increased Other Any increase in vocalization?* yes no Does your cat seem disoriented at times or unable to recognize familiar people?* yes no Does your cat seem stiff when moving, slow to rise, or less agile?* yes no Does your cat use a scratching post?*If you have other pets in the household, describe the cat’s relationship with them:*Has your cat ever shown any growling, hissing, or mouthing/biting towards you or anyone else? If so, when?*Are there things your cat is afraid of or does not like? If so, please describe.*Have you noticed any changes in your pet's personality or behaviors?*Has your cat shown any of these signs? Select all that apply coughing sneezing itching diarrhea vomitting Have you noticed any change in grooming or sleeping habits?* yes no Have you noticed any change in water or food consumption?* yes no Have you noticed any change in frequency of urination or defecation?* yes no Please rate your pet's itchiness score from 1-10, 1 being not itchy at all, 10 being extremely itchy.*12345678910Stool Quality Score*Please rate your pet's stool quality score from 1-5, 1 being profuse diarrhea, 5 being extremely hard.12345Stool SamplePlease bring a stool sample to your pet's appointment.What food are you feeding your cat? Please upload a photo below: Drop files here or Select files Max. file size: 300 MB. Is your pet fed a grain-free diet? Yes No Is food available all the time or at set "mealtimes"?*What human food/homemade cooking or treats does your pet get?*Does you cat hunt mice and wildlife?* yes no unsure How much time does your cat spend outside unattended or roaming freely?*Is your cat on flea/tick prevention currently?* yes no Have you seen any fleas on your cat in the last year?* yes no What, if any, medications (over the counter or prescription) does your cat take or have applied routinely?*Does your cat have a history of vaccination reaction?* Yes No Never been vaccinated If things go well and your cat is not exhibiting any signs of stress, are you interested in having him/her microchipped with a Tchip today?* yes no he/she is already microchipped Please list any questions/problems/concerns for Dr. Jinni that you would like addressed:Does anyone in your household have a peanut allergy?* Yes No Δ