Your Name:Date MM slash DD slash YYYY Cats Name:Cats Age:PART 1: Risk Assessment (To be completed by pet owner)Do you have multiple pets? Yes No Does your cat go outdoors? Yes No Does your cat share it’s outdoor bowls with any outdoor or feral cats? Yes No Do you ever take your cat to a boarding facility or groomer? Yes No How often?Do you ever travel with your cat? Yes No If so, where?Do you ever take your cat to cat shows? Yes No Does your cat interact with feral or unvaccinated cats? Yes No Do you have any feline leukemia positive cats at home or any untested cats? Yes No Do you have any FIV or FIP positive cats in your household? Yes No Has your pet ever become sick or had a reaction after vaccination? Yes No If so, which vaccine and what type of reaction?Is your cat on heartworm prevention medication? Yes No If so, what brand?Has your cat missed a monthly heartworm prevention dose? Yes No Does your cat have any known diseases? Yes No If so, what type?Is your pet on any other medications? Yes No If 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 Year 3 Year Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY
