Wellness History Form in Queenstown, MD | Mid Atlantic Cat Hospital

Name

This field is for validation purposes and should be left unchanged.

Patient Name*

Client*

First Last

Date*

Drinking*

Increased
Decreased
Normal

Last drank*

Appetite*

Increased
Decreased
Normal

Last ate*

Urination*

Increased
Decreased
Normal

Last urinated*

Defecation*

Increased
Decreased
Normal

Last bowel movement*

Any Diarrhea?*

Yes
No

Frequency

Liquid
Soft
Increased frequency

Any Vomiting?*

Yes
No

Frequency

Food
Bile
Other

If "other", please describe

Any Coughing?*

Yes
No

Frequency/ Describe

Any Sneezing?*

Yes
No

Frequency

Clear
Mucus

Is your cat on any monthly flea and/or heartworm preventatives?*

Yes
No

If yes, brand AND date of last dose

Is your cat on any regular medications?*

Yes
No

Medicine #1

Frequency

Dose

Last given

Medicine #2

Dose

Frequency

Last given

Medicine #3

Dose

Frequency

Last given

What is your cat's regular diet brand/feeding schedule?*

Lifestyle*

Indoor only
Indoor/Outdoor
Outdoor only

Any other issues or specific concerns you would like addressed today?*

Do you need any prescription refills or food today?*

Special Requests*

Nail Trim ($16)
Ear Cleaning ($23)
Other

Please specify

We ask that you please remain in your vehicle or on-site during the exam. One of our doctors or staff members will contact you by phone as soon as the exam is complete to discuss findings and any recommendations or necessary treatments and to obtain payment electronically (if paying by cash or check, please let us know in advance).

Please read and initial:

By initialing, I am authorizing Mid Atlantic Cat Hospital to examine my cat. I understand that I will be contacted with the exam findings and to discuss any recommended diagnostics or treatments that may be necessary.*

Sedation authorization - Please read and initial ONE of the following:

If a light sedative is necessary to help my cat's anxiety or stress in order to allow for a more complete exam or completion of diagnostics or treatments , I authorize the doctor to sedate my cat. This sedative may be either an oral medication or an injection given that helps to "take the edge off." It does not fully sedate the cat.

I do not authorize any sedation of my cat. Please call if sedation is deemed necessary

Signature of Owner/Agent*

Primary Phone # to contact you at*

We thank you for your understanding as we work to continue to provide you the exceptional care you have come to expect during this difficult time. Thank you for choosing us today and trusting us with your cat's care! We hope to resume normal operation and hours as soon as possible.