Glastonbury CT Vet

Feline Check-In Form

Please fill out the following information to help us better identify area of concern.

Client

Patient

Breed

Sex

Age

 

1. Does your animal have any of the following warning signs? CHECK all that apply.

Swelling/lump that persists or continues to grow

Difficulty eating or swallowing (chewing habit changes)

Weight gain/loss for no apparent reason

Loss of normal appetite OR increased appetite

Unusual discharge from the mouth/nose/urinary tract/rectum/vagina

Discolored teeth (yellow/brown/gray) or broken teeth

Bleeding from the mouth or gums

Offensive odor, especially from the mouth

Drooling or dropping of food

Facial swelling

Pawing at mouth/ears/face

Sore or sores that do not heal

Hesitation to exercise; loss of strength, energy or stamina

Difficulty breathing (shortness of breath, labored breathing, excessive panting, etc)

Chronic cough

Fainting / collapsing

Frequent vomitting or diarrhea

Poor hair coat quality

Sudden pain or paralysis, usually the back legs

Changes in urination or defication (straining/blood/etc)

Increased drinking / changes in water consumption

Ear inflammation OR discharge (scratching ears)

Biting or licking at feet or back legs

None of these signs

 

2. Is your animal exposed to second-hand smoke, toxins or impurities in the air, or cancer-causing chemicals to the fur?     Yes     No

3. Do you measure your animal's food daily?     Yes     No

4. What does your animal eat? (brand)    

5. Have you ever missed or gotten off schedule in providing your animal with the prescribed heartworm / flea / tick prevention medication?     Yes     No

6. Does your animal appear stiff or lame when rising from bed, have a change in gait, dislike being touched or exhibit any signs of pain such as reluctance to stand, climb stairs, jump on a chair or windowsill, or have difficulty in performing any of these activities?     Yes     No

7. Do we have your permission to use a picture of your pet for our marketing campaigns? Yes     No