Senior Health Questionnaire

Do you have a cat or small dog who is 10 or older, or a large dog 8 or older? Well, then you are the proud owner of a senior who needs a little extra care. Your pet may appear healthy and still youthful but there can be hidden problems and if dealt with early can add years to your pet’s life.

We recommend a senior screen every 12 months, which includes blood pressure, ECG (for the heart) and an annual chemistry and CBC screen.

Did you know senior pets need to have their nails trimmed more frequently? We commonly see our senior pets with overgrown nails or nails grown into pads. If you are uncomfortable trimming nails we can teach you or do them for you. Every 11th nail trim is free – pick up your nail trim card today!

Our pet companions can be considered senior pets as early as seven years old. Due to their relatively shorter lifespan compared to humans, the aging process can progress quite rapidly. By answering the following simple questions, together we can identify certain disease processes early on, allowing earlier intervention and slowing down or reversal of progression, thus extending the healthy quality of life of your beloved companion.

Full Name (Primary Owner) *

Email *

Phone *

Pet's Name *

Pet's DOB / Age *

Breed *

Please indicate if your pet has any of the following symptoms:

Difficulty climbing stairs	Yes No
Difficulty jumping up	Yes No
Increased stiffness or limping	Yes No
Loss of housetraining	Yes No
Increased thirst	Yes No
Increased urination	Yes No
Changes in activity level	Yes No
Excessive panting	Yes No
Other changes in breathing pattern	Yes No
Coughing	Yes No
Circling or repetitive movements	Yes No
Aimlessly wanders or paces	Yes No
Follows you everywhere	Yes No
Less interaction with family	Yes No
Decreased responsiveness	Yes No
Appears lost in yard or house	Yes No
Sleeps more during the day	Yes No
Stares into space or at walls	Yes No
Sleeps less at night	Yes No
Increased vocalization	Yes No
Increased anxiety	Yes No
Increased aggression or irritability	Yes No
Changes in skin and/or coat	Yes No
New lumps and/or bumps	Yes No
Excessive scratching	Yes No
Muscle tremors or shaking	Yes No
Less enthusiastic greetings	Yes No
Increased appetite	Yes No
Decreased appetite	Yes No
Vomiting	Yes No
Changes in bowel movements	Yes No
Weight loss	Yes No
Weight gain	Yes No
Difficulty hearing	Yes No
Vision problems	Yes No
Difficulty chewing/playing with toys	Yes No
Bad breath	Yes No

The name and brand of food I feed my pet is:

My pet eats people food

Never
Occassionally
Frequently

Is your pet on monthly flea prevention?

Yes
No

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Senior Health Questionnaire

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