New Feline Patient Form Name(Required) First Last Pet's Name(Required)Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone(Required)Work PhoneRecent History & Risk Factor EvaluationSince your last visit, some aspects of your cat’s lifestyle might have changed. We’ll use this information to help evaluate your cat’s health and individualize the care your cat receives, including vaccinations and examinations. Please indicate by circling which items below describe your cat’s lifestyle. My catGoes outside: Never Occasionally Always Lives with other cats: Yes No Is boarded: Yes No Comes into contact with cats other than house-mates: Yes No I plan to get an additional cat someday: Maybe Never Goes to a groomer: Yes No Lives with or visits an immunocompromised person: Yes No Please indicate if your pet is on any medication: Frontline Advantage Multi Other Do you need a refill for any of the above medications today? Yes No Has a Microchip: Yes No Please answer the following questions about your cat’s recent behavior.Current brand of diet:Appetite is: Normal Decreased Increased Weight: Stable Loss Gain Water consumption: Normal Decreased Increased Bowel movements: Normal Constipated Diarrhea Urination: Normal Decreased Increased Using litter box: Yes No Bad Breath: Yes No Vomiting: Yes No Coughing or gagging: Yes No Sneezing: Yes No Any listlessness: Yes No Any weakness: Yes No Shaking head: Yes No Hair loss: Patchy Generalized Shedding New lumps or bumps: Yes No Unusual discharge: Yes No Lameness: Yes No Difficulty rising: Yes No Reluctant to jump: Yes No Any behavioral changes: Yes No CAPTCHA Δ