Welcome New Clients! Book today and enjoy $30 off your pet’s first wellness exam* Book directly online or give us a call to schedule!

Fill out your Feline Consultation Questionnaire online.

Name: FMA Animal Hospital
Address: 4755 Rainbow Blvd, Westwood, KS, 66205, United States
Telephone: 913-262-1600
Price range: $

Please fill out the form as completely as possible.

Owner Information
Name: *
First
Last
Address:
Address Line 1
Address Line 2
City
State
Zip Code
Home Phone:
Cell Phone:
Employer's Name:
Employer's Address:
Address Line 1
City
State
Zip Code
Work Phone:
Email: *
Name of preferred local pharmacy:
Phone:
Fax:
Basic Feline Information
Feline's name: *
Age:
Breed:
Color:
Gender:
Female
Male
Spayed/Neutered?
Yes
No
Age when performed:
Weight:
Date and age when acquired (if known):
Source:
Breeder
Shelter
Stray
Rescue
Other
If Other, please explain:
Reason for obtaining this cat:
Litter size (if known):
Age when weaned (if known):
Bottle fed:
Yes
No
Describe your cat's personality:
Has your cat been bred?
Yes
No
If so, at what age?
How much interaction did the kitten have with people in the first year of life?
What method of litter training was used?
Your reaction to mistakes during litter training:
Was there any interaction with other cats during the first year? If so, provide details:
Are you the cat's first owner?
Yes
No
Feline Medical History
Please ensure that we have all your pet's medical records
Primary veterinarian:
Clinic name:
Phone:
Fax:
Date of last veterinary visit:
Please list the most recent set of vaccinations received and the date(s):
Date wormed:
Referred by:
Provide medical history (infection/surgeries) and prescribed treatment:
Current/regular medications (such as allergy, heartworm, herbal, over the counter, pain medication, supplements, topical flea and tick treatment) - please specify medication, dose, route, frequency given.Medication: Dose: Route: Frequency Given:
Route administered (oral, topical, eyes, ears, etc.)
Has there been any change in the following? (Please select all that apply):
Eating
Drinking
Please explain change in eating habits:
Please explain change in drinking habits:
Have you noticed any of the following? (Please select all that apply):
Coughing
Sneezing
Vomiting
Diarrhea
Has your cat ever been treated for its behavior in the past?
Yes
No
If so, describe the treatment and medication (if applicable):
Does your cat have seizures or has it ever had any seizures?
Yes
No
Current Human Household Members
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Name:
Age:
Occupation:
Other Household Pets
Have you owned cats previously?
Yes
No
Have you owned this breed of cat previously?
Yes
No
Have you owned other pets previously?
Yes
No
Current pets in the household:
Name, Type and Breed:
Age:
Spayed or neutered?
Yes
No
Relationship with cat (fight, play, avoid)
Name, Type and Breed:
Age:
Spayed or neutered?
Yes
No
Relationship with cat (fight, play, avoid)
Name, Type and Breed:
Age:
Spayed or neutered?
Yes
No
Relationship with cat (fight, play, avoid)
Name, Type and Breed:
Age:
Spayed or neutered?
Yes
No
Relationship with cat (fight, play, avoid)
Diet and Feeding Habits
Type(s) of food:
Dry
Canned
Both
Brand(s) (e.g., Purina, Eukanuba, Friskies):
Who is primarily responsible for the feeding?
Quantity of food given:
At what approximate time(s) of day is food given?
Where is the cat fed (physical location)?
Where is the cat fed in relation to other cats in the household?
Describe your cat's appetite:

Good Average Poor

GoodItem #1 Good
AverageItem #1 Average
PoorItem #1 Poor

At what speed does it typically eat?

Fast Slow

FastItem #1 Fast
SlowItem #1 Slow

Do you have to be present for your cat to eat?
Yes
No
What are your cat's favorite foods?
How much water does your cat drink in a day?
How many water bowls are provided?
How much milk does your cat drink in a day?
Do you add any supplements or tidbits to your cat's diet?
Yes
No
If so, provide details:
Daily Activities
Where does your cat sleep at night?
Where does your cat sleep during the day?
When does your cat get up in the morning?
Is your cat very active at night?
Yes
No
If yes, how often and have you any idea why?
Does your cat seek out high places to rest?
Yes
No
Where can your cat normally be found during the day?
Is your cat allowed to go outside?
Yes
No
If so, how long does it like to stay out for in the summer?
If so, how long does it like to stay out for in the winter?
Is access controlled by your or does the cat have free access through a cat door?
Controlled access
Free access through cat door
How often do you see other cats in your yard?
Daily
Several times per week
Occasionally
Rarely
Never
Is the yard fenced?
Yes
No
What area is available for the cat to roam outside?
How far does your cat roam on average?
It stays in the yard
It may go next door or two doors away
I do not know how far it roams when outside
Have there been any changes in your household routine (e.g., new baby, change in working hours, moving, new roommate, visitors, dietary changes) or living arrangements?
Elimination Behavior
Do you provide a litter box?
Yes
No
How many litter boxes are provided?
Has there been a change in the number of litter boxes provided?
Yes
No
If yes, how recently? From how many to how many?
Has there been a change in litter box location?
Yes
No
If yes, how recently? From where to where?
What types of litter boxes are provided?
Covered
Uncovered
Both are provided
Describe the shape and size of each box:
What type and brand of litter is used?
Are odor-control granules added?
Yes
No
Have you changed the litter material brand or type?
Yes
No
If yes, how recently? From what, to what?
How often is the waste material scooped out?
How often is the litter box completely cleaned out and washed?
Have you changed the scooping or cleaning frequency?
Yes
No
If yes, how recently? From what, to what?
What do you use to clean and wash the actual box?
Does the cat use the litter box on a regular basis?
Yes
No
How many times per day does it use the box?
Does the cat use the litter box for:
Urine only
Feces only
Both
Neither
Does the cat bury its urine?
Yes
No
Does the cat bury its feces?
Yes
No
Is there much digging and scratching in and around the litter box?
Yes
No
Problem elimination behavior (if applicable)
What is the cat leaving outside the litter box?
Urine only
Feces only
Both
How often does this occur?
Once a week
Once a month
Once a day
Always
How long has this behavior been going on?
What time of day do you usually find the deposits outside of the litter box (e.g., morning, afternoon, after work, overnight)?
Where is the cat eliminating outside the box? Please list room, locations, number of deposits:
When the problem first began, can you recall any unusual incident occurring at that time or anything that might have upset the cat (e.g., new roommate, moving, change in working hours, addition of another pet, new baby, dietary changes)?
Yes
No
If yes, please explain:
Have you ever caught the cat depositing urine or feces outside the litter box?
Yes
No
If yes, what was your response and what was the cat's response?
What posture does the cat assume when eliminating outside the litter box?
Standing upright
Squatting
Where is the urine located?
On the floor
On the walls, 6-8 inches above the floor
Is the cat spraying or urinating?
Spraying
Urinating
If you are not the cat's first owner, did the cat have similar issues in its previous home(s)?
Yes
No
N/A
Don't know
Does the cat have a history of urinary tract infections?
Yes
No
When was the last time a urine sample was examined by your veterinarian?
What approaches (medical, environmental, or behavioral) have been used in the past to attempt to address the problem?
Was any approach effective in decreasing or eliminating the problem behavior?
Yes
No
If yes, please specify:
Territorial Behavior
Does your cat defend its territory against other cats?
Yes
No
If so, which cats?
Unfamiliar cats outside
Housemates
Housemates Names:
Describe your cat's appearance when defending its territory:
Does your cat fight with any of the other cats in the home?
Yes
No
Names:
Do you ever see this cat physically blocking a housemate cat from accessing food, litter, boxes, rooms, toys, or climbing perches?
Yes
No
Names:
Do you ever see another housemate cat physically blocking this cat from accessing food, litter boxes, rooms, toys, or climbing perches?
Yes
No
Names:
Does your cat catch prey and bring it into the house?
Occasionally
Regularly
Never
What type of prey does it catch?
Play Behavior
Is your cat playful?
Yes
No
Is there any specific time devoted to play or training on a daily basis?
Yes
No
Does your cat play games with you or with other family members?
Yes
No
If yes, provide details:
Who initiates play?
Cat
Family members
What types of toys does your cat play with?
String
Feathers
Balls
Laser
Other
If other, provide details:
Does your cat come when called or do any tricks?
How does your cat respond to catnip?
Home Alone
Where does your cat stay during the day when no one is home?
Crate
Specified room
Free run (in house)
Outside
Other
If other, provide details:
What arrangements are made for the cat if you are away from home for some time (e.g., on vacation)?
Typically, how long is your cat left alone without human company on any given day?
Scratching Behavior
Has your cat been declawed?
Yes
No
If yes, which paws?
Front two paws
All four paws
At what age was your cat declawed?
Do you have one or more scratching posts for the cat?
Yes
No
Describe the type and location of the post(s):
Does your cat use the scratching post(s)?
Yes
Sometimes
Never
My cat scratches on other things
Please describe:
Interaction with Family Members
What type of home do you have?
Apartment
House
Condo
Townhome
Other
If other, provide details:
How would you describe your home?
Quiet
Lively
Chaotic
To which areas of your home does your cat have access?
Does your cat have a reaction to handling in any of the following circumstances? (Please select all that apply and elaborate when prompted):
Brushing/grooming
Petting, hugging, or holding
Disturbed when resting
Disciplining
Playing
Giving Treats
Putting the cat in the carrier
Please describe your cat's reaction, the type of aggression they may exhibit (growling, hissing, nipping, scratching, showing teeth, or biting) and who they reacting to (adult owner, child, other individual):
Please describe your cat's reaction, aggression exhibited, and to whom during brushing/grooming:
Please describe your cat's reaction, aggression exhibited, and to whom during petting, hugging, or holding:
Please describe your cat's reaction, aggression exhibited, and to whom when disturbed during resting:
Please describe your cat's reaction, aggression exhibited, and to whom during disciplining:
Please describe your cat's reaction, aggression exhibited, and to whom when playing:
Please describe your cat's reaction, aggression exhibited, and to whom when giving treats:
Please describe your cat's reaction, aggression exhibited, and to whom when putting the cat in the carrier:
Interaction with Others
How does your cat behave when visitors come to the house (e.g., hides, shows interest in visitors, interacts with them)?
Is the behavior different towards familiar and unfamiliar people?
Yes
No
If yes, provide details:
Is your cat quick to approach new people?
Yes
No
Has your cat ever bitten or attacked anyone?
Yes
No
If yes, and this is not the primary complaint at the present time, please provide brief details:
Are there any regular visitors to the home?
Yes
No
If yes, please provide the information (Name(s), purpose(s), time and days, cat's reaction(s))
What is your cat's response to frequent visitors?
What is your cat's response to occasional visitors?
What is your cat's response to rare visitors?
Please check any of the following that your cat has a negative reaction to and elaborate when prompted:
Familiar men
Familiar women
Familiar children
Unfamiliar men
Unfamiliar women
Unfamiliar children
Familiar cats
Unfamiliar cats
Other animals (e.g., dogs, squirrels)
Crowds and busy areas
Where does your cat have negative reactions to familiar men?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to familiar women?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to familiar children?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to unfamiliar men?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to unfamiliar women?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to unfamiliar children?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to familiar cats?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to unfamiliar cats?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to other animals?
Inside the home
Outside the home
Details:
Where does your cat have negative reactions to crowds and busy areas?
Inside the home
Outside the home
Details:
Other Behaviors
When does your cat meow?
When does your cat growl?
When does your cat purr?
Is your cat aggressive when it is denied something it wants?
Yes
No
If yes, please describe this behavior:
Does your cat ever show inappropriate mounting or other sexual behavior?
Yes
No
Details:
Does your cat tolerate, enjoy or resist grooming?
Tolerate
Enjoy
Resist
Does your cat tolerate, enjoy or resist handling?
Tolerate
Enjoy
Resist
Does your cat lick or chew itself more than you would expect?
Yes
No
If yes, give details:
How do you correct your cat when it misbehaves?
Are there any other behaviors that you find objectionable, feel you should mention, or wish to discuss?
Yes
No
If yes, describe these:
The Current Problem
Describe the problem you are currently experiencing with your cat:
When did this problem begin?
Did it coincide with any event or action that you can identify?
Is this a chronic (constant) or intermittent problem?
Chronic
Intermittent
How old was the cat when the problem began?
Where does the problem commonly occur?
With whom does it occur?
How often does it occur?
What approaches have been tried to correct the problem?
Is the problem getting better or worse?
Better
Worse
No Change
Do you suspect any cause?
Describe the three most recent episodes of the behavior:
Is there any legal action pending because of this cat's behavior?
Yes
No
If yes, please explain in detail:
Aggression Section (if applicable)
Describe the most recent incident and the setting in which is occurred (be precise):
Where was the cat?
Where was everyone else in relation to the cat?
What was everyone doing prior to the incident?
What was the cat's body posture (position of ears, tail, face, fur)?
What was your reaction or response?
What was the cat's reaction to your response?
Was any form of punishment used?
Yes
No
If so, give details:
Was there a bite or scratch wound?
Puncture
Tear
Scratches
Describe the previous three incidents prior to the most recent incident:
How frequently does this type of incident occur?
Several times a day
Several times a week
Daily
Weekly
Monthly
Other
If other, please explain:
Does this problem occur when the cat is left alone?
Always
Sometimes
Never
Does this problem occur when the family members are present?
Always
Sometimes
Never
What has been done to correct the problem?
Is the problem getting better or worse?
Better
Worse
No Change
Do you suspect any cause?
Relationship with Feline
How would you describe your own and your family's relationship with this cat? (Adult owners & children)
What are your own and your family's feelings about the cat's present behavior? (Adult owners & children)
What is your expectation for change?
Under what circumstances would you consider rehoming this cat?
Under what circumstances would you consider relinquishing this cat to a shelter or rescue?
Under what circumstances would you consider euthanasia?
Video Recordings
Video recordings of the specific problem are extremely helpful for verifying your descriptions. Never* place any person or animal in danger in order to obtain video information. Feel free to bring the video recordings with you (on your phone, tablet, laptop, etc.) to your consultation. Please do not email videos ahead of time.
Upload Videos:

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Describe the scenarios seen in videos:
*
What is 1+4?

Website

We proudly serve the pets Westwood, KS and beyond.

We're a full service, state of the art animal hospital located in Westwood and serving the surrounding Kansas City area.

Directions

4755 Rainbow Blvd
Westwood, KS 66205

Click here for directions.

Call Us

913-262-1600

Hours

Mon – Fri: 7 am – 7 pm
Sat: 8am – 5 pm
Wed: Closed from 12:30-2:00 pm

Have a question? Drop us a line and we'll get right back to you.

Request an Appointment Online!

Use our online apppointment request form to request an appointment online in minutes.

BOOK APPOINTMENT