BHVH - Feline Patient History Questionnaire

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Please use this form to send us information we need to give your cat the best possible medical care.

When you arrive, please ring the doorbell to let us know you are here and someone will come and help you with your four legged friend! While you wait outside, the doctor will perform their exam and call you to go over their findings.

Email *

What is your cat's name? *

What is your first and last name? *

What phone number should the doctor use to speak with you?

What is the date and time of your appointment? *

YYYY

Time

Please briefly describe the primary reason for your pet's visit.

Do you have any reason to suspect that your animal has been in contact with anyone who was exposed to COVID-19 (Corona Virus)?

Yes

Unsure

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How is your cat feeling?

Doing great! Everything is back to normal or is better than it has been!

Doing well. My cat is feeling the same as he or she always does.

I'm concerned. My cat is displaying some odd behavior.

I'm worried. My cat is not acting like him or her self at all.

My cat is displaying highly worrisome behavior. Please call the hospital immediately at (718) 624-1200. If we are closed or no one answers please call Blue Pearl or VERG immediately.

Other:

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Have you noticed an increase of any of the following? Please select all that apply.

Coughing. My cat is coughing more than usual.

Sneezing. My cat is sneezing more than usual.

Vomiting. My cat is vomiting more than usual.

Diarrhea. My cat is having diarrhea for longer than is normal.

Soft stool. My cat is having soft stool for longer than is normal.

None of the above

Other:

How is your cat's appetite?

It has increased. My cat's appetite is higher than normal.

It's the same. No change.

It has decreased. My cat's appetite is lower than normal.

Other:

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Are there any changes to your cat's drinking habits?

My cat is drinking more than normal.

My cat is drinking the same as he or she always does.

My cat is drinking less than normal.

Other:

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Are there any changes in your cat's urination?

My cat is urinating more than usual.

My cat is urinating the same amount as he or she always has.

My cat is urinating less than normal.

Other:

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Is your cat displaying any odd or unusual behaviors when he or she uses the litterbox? (if yes, please specify)

Is your cat scratching his or her ears or shaking his or her head more than usual? (if yes, please specify)

What kind of food are you feeding your cat?

Wet. I feed my cat wet food.

Dry. I feed my cat dry food.

I feed a combination of wet and dry

Please specify food manufacturer and type.

How frequently do you feed your cat?

Once per day.

Twice per day.

Three times per day.

I put down food and my cat eats when he or she is hungry.

Other:

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How much food do you feed your cat per feeding?

Is your cat groomed or boarded at a facility?

Yes

Other:

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Are there any other pets in your home? (if yes, please specify)

Do you travel with your cat outside of Brooklyn or New York City? (if yes, please specify)

Is your cat an indoor cat or does your cat go outside?

Indoor only.

Goes outside.

Other:

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Does your cat take heartworm or parasite prevention?

Yes. My cat takes both heartworm and flea & tick preventatives.

My cat ONLY takes flea & tick preventatives.

My cat ONLY takes heartworm preventatives.

My cat does not take either heartworm or flea & tick preventatives.

Other:

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Do you need more flea and tick preventative? If so, what products do you use and how many months would you like?

Is your cat currently taking any medication? (if yes, please specify medication name, dose, and how frequently you administer it)

Do you need refills of any medictions? If so, which ones?

Are you able to get your cat to take pills?

Yes

I've never tried

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Does your cat have a history of vaccination reactions?

Yes

I don't know

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Are there any other questions or concerns that you'd like the doctor to know?

Submit

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