Senior Canine/Feline Questionnaire (over 7 years of age) Owner’s Name Date Address Postal Code Phone numbers (home) (cell) (work) Emerg. Contact(other than immediate family ): ph: Email Pet’s Name Breed Colour Sex Male Female Neutered Spayed Age or Birthday Have you noticed any: Loose Stools Vomiting Coughing Heavy Breathing Sneezing Eye Discharge Itching Hair loss Fleas Ticks Aggression Skin Growths Other Does your pet exhibit: Poor Housetraining Habits Unwanted Aggression Excessive Vocalizing Undesired Marking Behaviors Other Other Any changes in the ability to walk , jump or run? Yes No What kind of dental care are you providing for your pet? Does your pet have difficulty hearing or respond less quickly when called? Yes No Does your pet have difficulty seeing? Yes No Is your pet drinking more water than a year ago? Yes No Any changes in sleep habits? Yes No Does your pet seem to have the same energy, stamina and strength as last year? Yes No Where does your pet sleep? Does your pet have bad breath? Yes No Does your pet exhibit any of the following signs ? constipation retraction from touching lack of grooming (cats) overgrooming (cats) isolation limping/change in gait avoiding stairs weight loss grouchiness change in posture sudden aging What brand of food are you feeding your pet? How much and how often? Do you give any vitamins or nutritional supplements (including glucosamine and Aspirin) ? Yes No If yes, what and how much? Do you have other pets? If so, how many? Dogs Cats Other Other Are your other pets on flea, heartworm and parasite prevention ? Yes No Are the other pets vaccinated? Yes No How much time does your pet spend outdoors? Does your pet have trouble eating (chewing on one side, dropping food)? Yes No Please list any medications (either prescription or “over the counter”) your pet receives, including amount and frequency.PhoneThis field is for validation purposes and should be left unchanged.
