Dog, cat and
ferret
questionnaire
Dog, Cat and Ferret Questionnaire
Age:
Pets Name:
Breed:
less than 6 months
6-12 months
1 year
2 years
3-5 years
6-9 years
10-13 years
14 and up years
Female
Male
1-3 months
3-6 months
6-9 months
12 + months
unknown
Neutered
Non-Spayed Females Last Heat:
Rarely outside
Where does your pet live?
Indoor
Outdoor
In and out freely
What vaccinations has your pet had in the
last 1 to 3 years?
Distemper
combination
Bordetella
complex
6 months to 1 year
1 to 2 years
2 to 3 years
Over 3 years
Unknown
N/A
6 months to 1 year
1 to 2 years
3 years
more than 3 years
unkown
Never
Was your pets last rabies vaccination the
first one they had ever received?
6 months to 1 year
1 to 2 years
2 to 3 years
3 years
Over 3 years
Unknown
Never
Rabies
Yes
No
Unknown
Feline
Aids
Less than 1 year
1 to 2 years
2+ years
Unknown
Never
N/A
Less than 1 year
1 to 2 years
2+ years
Unknown
Never
Feline
Leukemia
6 months to 1 year
1 to 2 years
2+ years
Unknown
Never
N/A
Lyme disease
Other
Vaccinations?
Has your cat been tested
for feline leukemia?
If yes to was tested,
was your cat
Yes
No
+
-
If yes to was tested,
was your cat
Has your cat been
tested for feline AIDS?
+
Yes
-
No
Is your pet on heartworm
prevention?
Has your pet been
tested for heartworm?
Yes
Yes
No
No
Has your pet tested positively for Lyme
disease?
No
Yes
Is your pet currently on ANY medications or
supplements?
No
Yes, please list below
Your phone number:
Your Name:
