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PET INFORMATION     Date _________  Pahle Small Animal Clinic

 Cat’s Name ___________________________________ D.O.B. _____________

 Breed _________________________________ Male/Female   Neutered/Spayed

 Do you have more than one pet?  Yes   No

# of cats? ________ # of dogs?  ________ Other _________________________

Help us learn more about your cat’s lifestyle by checking all that apply:

 (  )     My cat lives totally indoors, never going outside, even on an enclosed porch

(  )     I feed the strays in my neighborhood or bring stray cats inside.

(  )     My cat never sits in an open window or is exposed to the outside

(  )     My cat is declawed

(  )     My cat loves to sit on the screened-in porch or on the sill in front of an open window. 

            The porch or window is located on the

            (  ) first floor 

(  )  second floor or above

(  )     My cat stays in the backyard at all times

(  )     My cat is outdoors only, never coming indoors

(  )     My cat is indoors most of the time and only goes outside in the yard

(  )     My cat loves to roam the neighborhood

(  )     I remove ticks from my cat daily/weekly/monthly/never

          (Circle the one that applies)

(  )     My cat gets into fights with: (  )other cats (  )dogs (  )other ______________

(  )     My cat goes to the groomer every _____ weeks

(  )     A groomer comes to my premises to bathe my cat

(  )     My cat has tested positive for feline leukemia in the past

(  )     My cat has tested positive for feline AIDS in the past

(  )     My cat was purchased from a store/humane society/animal control

(  )     My cat was adopted from a private household (not a breeder)

(  )     My cat was a stray

(  )     My cat was purchased from a breeder (Registered name ______________)

(  )     My cat appears in cat shows

(  )     My cat boards when we go away on vacation

(  )     A pet sitter comes to my house when we go away on vacation

(  )     My cat is afraid of: (  ) other cats (  ) dogs (  ) people

(  )     My cat is afraid to visit the veterinary clinic

 VACCINATION ASSESSMENT FORM

 ____________________________ has been assessed to be:

 (  )  an indoor only cat                               (  )  a show cat

 (  )  an indoor/outdoor cat                         (  )  a breeding cat

 (  )  an outdoor only cat

 Based on this assessment, your cat should receive the following vaccinations:

 I understand that this vaccine protocol has been tailored for my cat’s current life style and to reduce the risk of adverse events that may be associated with vaccination.  I will notify Pahle Small Animal Clinic immediately should my cat’s life style change in any way.

 I understand that vaccination of my cat with the above vaccines will substantially reduce but may not completely eliminate his/her chances of contracting the disease.

 I understand that should my cat develop any severe or unanticipated reactions after vaccination that I should contact Pahle Small Animal Clinic immediately for instructions.

 I have discussed the above protocol and have asked any questions I have concerning this vaccination protocol.  All such questions have been answered to my satisfaction.

 _________________________         _______________________________         __________

Signature of client        Signature of veterinarian     Date

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