Your name:_____________________________  Today’s Date:___________

Pet’s Name:___________________ Your Relationship to Pet:_______________________

Basic Information

Species_________________

Breed___________________

Age:________            Years owned:_____

Check one:    Male - intact     Male - neutered     Female - intact      Female - spayed

Approximate weight:_____pounds

Last known approximate date of vaccinations(month and year):____/________

Why have you sought help from Arms of Aloha today? What can we do for you?

Diet, including treats and people food. Note any recent changes.

Is the pet taking any

prescription medications?     Yes     No

over the counter medications?     Yes     No

nutritional supplements or natural remedies?     Yes     No


How many people live in the home, and what are their approximate ages (elderly, young child, adult etc. are fine):

What other pets live in the home?

Are there frequent visitors to the home?

What are the things that your pet enjoys most in life?

How does your pet typically respond to medical procedures or visits to the vet office?

Have you noticed any changes in your pet’s behavior?

Medical

Please list any known medical issues or diagnoses:

Check any of the following problems your pet is experiencing or has had in the past:

Problem

Currently Experiencing

Previously Experienced

Vision Problems

Coughing

Trouble Breathing

Trouble Chewing

Bad Breath

Weight Loss

Vomiting

Diarrhea

Nasal discharge

Excess gas / gurgling stomach

Odor in Ears

Scratching Ears

Shaking Head

Trouble Hearing

Swelling or Lumps

Scooting

Confusion

Energy Level and Exercise: 

Have you noticed any recent changes in your pet’s activity level or energy?     Yes     No

Have there been changes in your pet’s ability or willingness to exercise or do activities that he or she normally does?     Yes     No

Does your pet tire easily or faint? Describe circumstances if observed.     Yes     No

 

Mobility

Does your pet appear overall stiff or sore?     Yes     No

Is he or she limping on a particular leg?     RF      LF      RH      LH

Any reluctance to engage in previous activities?     Yes     No

Does your pet have difficulty:

with stairs?     Yes     No     N/A

with jumping onto bed/couches/into cars/onto counters?     Yes     No     N/A

with positioning him or herself to urinate or defecate?

   Urination      Defecation      Neither      Both      Don’t Know

Have you noticed any difficulty upon sitting or rising? Does time of day or length of rest period make a difference?    Yes    No

What does your pet like to play with?

Any decrease in interest in toys?    Yes     No     Don’t Know

Appetite

Rate your pet's appetite from 1 to 10, with 10 being his or her "normal" appetite._____

Are there any recent changes?    Increased     Decreased     None     Not Sure

Have you noticed an increase or decrease in the amount of water your pet is drinking?

   Increase        Decrease        None       Unsure

Urination

Have you observed your pet

straining to urinate?     Yes     No     Don’t Know

taking a long time to urinate?     Yes     No     Don’t Know

asking to go out more or less frequently?     Yes     No     Don’t Know

producing several small “puddles” of urine instead of one continuous stream?

   Yes     No     Don’t Know

appearing to need to urinate but then does not produce urine, or only a very small amount?

   Yes     No     Don’t Know

Have there been accidents (urine or defection) in house?      Yes      No

Is there a change in color of urine?    Yes      No     Don’t Know

odor?      Yes      No      Don’t Know

volume?     Yes      No      Don’t Know

Environment

Are there smooth surfaces in the pet’s environment, such as tile or wood floors?

Where is the food bowl located, and how is it positioned (on the floor, counter, raised platform etc)?

Cats: How many litter boxes are in the home?_____

Where are they located?

Are they covered or open?

Approximate height of side through which cat enters box:______inches

Where does your pet sleep? _______________________________________________

Are there stairs in your home, and if so, does your pet need to navigate them?

What percentage of the day does your pet typically spend outdoors?_____

Please describe which family members are home and at what times:

Other Questions (Optional)

For pets entering hospice, it often is helpful to think about what we want and need as life draws to its natural conclusion. The following information is particularly useful to us if your pet has a terminal diagnosis, but is good to think about at any point in life.

What makes life worth living for your pet?

What are the family's beliefs regarding euthanasia?

What past experiences has the family had that have helped shaped your views about end-of-life?

Please feel free to share any religious beliefs that you have about death that you would like us to know.

What are your preferences for aftercare? Most families opt for an individual cremation, with the ashes returned to them, or a communal cremation, where the ashes are scattered together in Kaneohe Bay. You can also choose a special urn or memorial (ask to see a catalog if interested). If you wish to bury your pet on your property, check with local zoning ordinances first.

For most families, finances are a major factor in medical decision making for pets. This is a completely normal and common concern. Please share any concerns you have about the affordability of care, if you have a specific budget in mind, or anything else you want us to know.