Your name:_____________________________ Today’s Date:___________
Pet’s Name:___________________ Your Relationship to Pet:_______________________
Age:________ Years owned:_____
Check one: Male - intact Male - neutered Female - intact Female - spayed
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?
Please list any known medical issues or diagnoses:
Check any of the following problems your pet is experiencing or has had in the past:
Excess gas / gurgling stomach
Odor in Ears
Swelling or Lumps
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
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
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
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
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.