Patient Name...........................................
Nurse.......................................................
Please fill out this questionnaire before attending your appointment. This will help us to fully
assess your pet and give us an idea of how they are at home. If there is anything you are unsure of,
please discuss this with the nurse at your consultation.
Once completed, please email to hayley@worcestervets.co.uk or bring with you to the
appointment.
Please tick all that apply to your cat, even if it only happens occasionally or even just once.
Behaviour
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My cat isn’t acting like himself/herself anymore
My cat interacts with us less/isn’t seeking attention
My cat seems confused/disorientated/displays odd behaviour (circle all that apply)
My cat meows/yowls for no apparent reason (circle all that apply)
My cat has toileting accidents/misses the litter tray (circle all that apply)
Body Functions
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My cat struggles to see/hear things (circle all that apply)
My cat has bad breath/dribbles/eats differently (circle all that apply)
My cat eats more/less than he/she used to (circle one)
My cat has lost/gained weight (circle one)
My cat is drinking more water
My cat uses the litter tray more often
My cat’s urine/faeces has changed (circle all that apply)
My cat vomits regularly (more than twice a month)
Daily Activity
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My cat is sleeping more often
My cat doesn’t want to play as often
My cat has difficulty jumping up onto the sofa/table
My cat struggles to negotiate the litter tray/goes in the wrong place (circle all that apply)
My cat seems stiff/uncomfortable/painful (circle all that apply)
My cat doesn’t like being handled anymore
Is your cat...
Indoor only
Outdoor only
Indoor and outdoor
Skin and Coat
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My cat does not groom himself/herself as well
My cat has been grooming more than usual
My cat has new lumps/bumps
My cat has a scruffy coat/matted fur/flaky skin (circle all that apply)
Heart and Lungs
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My cat’s breathing has changed
My cat coughs/sneezes (circle all that apply)
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My cat seems short of breath/tires easily
Any other comments?
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Please tell us about the food and treats your cat usually eats
When was your cat’s last flea and worm treatment administered? What products did you use?
When was your cat last vaccinated?
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Do you brush your cat’s teeth?
Yes
No
Do you groom your cat? If yes, please give details
Thank you for taking the time to complete the questionnaire- it will really help us to make a
thorough assessment of your pet. We look forward to seeing you soon!