Your Name:Date Date Format: MM slash DD slash YYYY Cats Name:Cats Age:PART 1: Risk Assessment (To be completed by pet owner)Do you have multiple pets?YesNoDoes your cat go outdoors?YesNoDoes your cat share it’s outdoor bowls with any outdoor or feral cats?YesNoDo you ever take your cat to a boarding facility or groomer?YesNoHow often?Do you ever travel with your cat?YesNoIf so, where?Do you ever take your cat to cat shows?YesNoDoes your cat interact with feral or unvaccinated cats?YesNoDo you have any feline leukemia positive cats at home or any untested cats?YesNoDo you have any FIV or FIP positive cats in your household?YesNoHas your pet ever become sick or had a reaction after vaccination?YesNoIf so, which vaccine and what type of reaction?Is your cat on heartworm prevention medication?YesNoIf so, what brand?Has your cat missed a monthly heartworm prevention dose?YesNoDoes your cat have any known diseases?YesNoIf so, what type?Is your pet on any other medications?YesNoIf so, please list type and dosage:PART 2: Your cat’s recommended immunizations (to be completed by veterinarian) Panleukopenia/Calicivirus/Rhinotracheitis/Chlamydia Rabies *Required by law for all pets* (Yearly) Feline Leukemia Vaccine 1 Year3 YearDate Date Format: MM slash DD slash YYYY Date Date Format: MM slash DD slash YYYY Date Date Format: MM slash DD slash YYYY
