Pre-Exam Questionnaire Date MM slash DD slash YYYY Client Name First Last Patient Name Age Pre-Exam QuestionnairePlease provide current address: Street Address City State / Province / Region ZIP / Postal Code Phone*Email* Would you like us to send you reminders? Email Text None Who is your pet insurance provider? Last time cat was outside? Access to a porch, deck, or yard? Are you currently using a flea preventative? If yes, which product? Are you currently using a heartworm preventative? If yes, which product? Would you like the doctor to apply a dose of Revolt (Generic Revolution) today? Yes (Cost $17.05-$18.98) No (Revolt is a topical preventive for fleas, heartworms, roundworms, hookworms, lice, and ear mites)Does your cat have trouble breathing? If so, how long?ALERT STAFF! Does your cat have active bleeding? If so, how long?ALERT STAFF! Is your cat coughing? If so, how long? Does your cat have bad breath? If so, how long? Does your cat have stiffness/trouble jumping? If so, how long? Does your cat have hairballs? If so, how long? Does your cat have litter box issues? If so, how long? Does your cat have constipation? If so, how long? Is your cat sneezing? If so, how long? Is your cat vomiting? If so, how long? Does your cat have diarrhea? If so, how long? What is your cat's current diet? Brand? Flavor? Canned food? Yes No Dry food? Yes No Amount and frequency given? Are there any issues/concerns you wish to discuss with the doctor? NameThis field is for validation purposes and should be left unchanged.
