Senior Canine/Feline Questionnaire (over 7 years of age) Owner’s NameDateAddressPostal CodePhone numbers (home)(cell)(work)Emerg. Contact(other than immediate family ):ph:Email Pet’s NameBreedColourSexMaleFemaleNeuteredSpayedAge or BirthdayHave you noticed any: Loose Stools Vomiting Coughing Heavy Breathing Sneezing Eye Discharge Itching Hair loss Fleas Ticks Aggression Skin Growths OtherDoes your pet exhibit: Poor Housetraining Habits Unwanted Aggression Excessive Vocalizing Undesired Marking Behaviors Other OtherAny changes in the ability to walk , jump or run?YesNoWhat kind of dental care are you providing for your pet?Does your pet have difficulty hearing or respond less quickly when called?YesNoDoes your pet have difficulty seeing?YesNoIs your pet drinking more water than a year ago?YesNoAny changes in sleep habits?YesNoDoes your pet seem to have the same energy, stamina and strength as last year?YesNoWhere does your pet sleep?Does your pet have bad breath?YesNoDoes 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) ?YesNoIf yes, what and how much?Do you have other pets? If so, how many?DogsCatsOtherOtherAre your other pets on flea, heartworm and parasite prevention ?YesNoAre the other pets vaccinated?YesNoHow much time does your pet spend outdoors?Does your pet have trouble eating (chewing on one side, dropping food)?YesNoPlease 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.
