Senior Canine/Feline Questionnaire (over 7 years of age) in Nepean, ON

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:

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 ?

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.

Phone

This field is for validation purposes and should be left unchanged.

Lynwood Animal Hospital

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Senior Canine/Feline Questionnaire (over 7 years of age)