Cat Lifestyle Assessment Form

Owner's Name: *

Email Address: *

Phone Number: *

Cat's Name: *

Age: *

Sex: *

Breed: *

Color: *

If more than one pet:

# of cats

# of dogs

Other:

Microchip number (if known):

Help us learn more about your cat by checking all of the following that apply:

My cat lives totally indoors, never goes outside, even on an enclosed porch.I feed the stray cats in the neighborhood.My cat never sits in an open window or is exposed to the outside.My cat is declawed.

My home or apartment has a chimney. Please describe the type of screen in front of your chimney.

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 floorsecond floor or above

My cat stays in the backyard at all times.My cat is outdoors only, never coming indoors.My cat loves to roam the neighborhood.My cat is indoors most of the time and only goes outside in the backyard.

I remove ticks from my cat:

DailyWeeklyMonthlyNever

My cat gets into fights with

Other CatsDogsOther

My cat visits or lives on a farm or other rural facilityMy cat goes to the groomer.A groomer comes to my premises to groom my cat.My cat has tested positive for feline leukemia or feline AIDS in the past.My cat was purchased from a pet store.

If yes, store name:

My cat was purchased from the humane society.My cat was adopted from a private household (not a breeder).My cat was a stray.My cat was purchased from a breeder.

If yes, registered name:

My cat boards when we go on vacation.My cat travels with me with we go on vacation.A pet sitter comes to my house when we go away on vacation.

My cat is afraid of:

Other CatsDogsPeopleMy cat is afraid to visit the veterinary hospitalI or someone in my family experiences chemotherapy, diabetes, or another immune suppressive disease/disorder.

How important is your pet's health to you?

How important is it to you that your pet is not in pain?

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