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Feline Functional Questionnaire
What is the main reason for today’s visit?
What is your primary goal for your cat today (ie determine cause of problem, reduce pain, improve mobility, etc)?
Please select how much difficulty your cat has with the following activities:
Jumps up on furniture
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Jumps on counters
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Jumps down
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Climbs stairs
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Descends stairs
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Plays
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Lies down
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Rises after rest
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Uses the litterbox
Easy
Somewhat hesitant
Very hesitant
No longer attempts
Interacts with family
Easy
Somewhat hesitant
Very hesitant
No longer attempts
What activities make your cat’s s symptoms worse?
What activities make your cat’s symptoms better?
Do you think your cat is in pain?
Yes
No
If yes, please describe:
Please list any past surgeries or major medical problems:
Please list all medications (include the name, dosage, and frequency):
Please list diet and treats given (include the name/brand, amount given, and how often):
Does your pet have any food allergies or sensitivities?
Yes
No
If yes, please describe:
What is your cat’s favorite treat?
Some of our treatments require direct skin contact. Do we have permission to clip/shave your pet’s fur?
Yes
No
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Your Name
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