Senior Pet Checkup Form
Email address *
Your name (first & last): *
Your answer
Pet name *
Your answer
Species *
Sex *
Breed *
Your answer
Color *
Your answer
Date of birth (approximate if not known) *
MM
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DD
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YYYY
NUTRITION
What does your pet eat? *
Your answer
Dry, canned, or moistened food? *
Please describe any snacks, supplements, or table scraps your pet receives, and how often. *
Your answer
Who in the family feeds your pet? *
Your answer
How many times a day does your pet eat? *
Your answer
How is your pet's appetite? *
Your answer
Have you observed any changes in your pet's eating habits or appetite recently? *
Your answer
ENVIRONMENT
Does your pet live: *
If ever outdoors, where does your pet sleep? *
Your answer
Do you have other pets? If so describe how many and what kind. *
Your answer
Are there young children in your household? *
Does your pet seek out warm places to lie down (such as radiators, heater vents, or fireplaces)? *
EXERCISE
What kind of exercise does your pet get? *
Your answer
How often do they get exercise? *
Your answer
Does your pet have any problems with this exercise? *
Your answer
Does your pet tire easily? *
Does your pet have trouble breathing, or does your pet begin coughing soon after exercise? *
WEIGHT
How do you monitor your pet's weight? *
Has your pet experienced any recent weight changes? If yes, please describe. *
Your answer
DENTAL CARE
Has your pet ever had his/her teeth cleaned? *
If so, how often? *
Your answer
When was the last time? *
Your answer
Do you ever brush your pet's teeth? *
Does your pet ever seem to have trouble chewing his/her food? *
BEHAVIOR
Have you noticed any changes in your pet's behavior recently? If yes, please describe. *
Your answer
Does your pet have any additional behavior problems? *
Have you recently felt that your pet was: *
Required
If you have noticed any of the above, when did you notice the change?
Your answer
SPECIAL SENSES
Have you noticed any changes in your pet's vision? *
Your answer
Does your pet run into objects or become anxious in an unfamiliar environment? *
Your answer
Have you noticed any changes in your pet's hearing? *
Your answer
Is your pet sometimes less responsive to commands? *
Your answer
OTHER INFORMATION
How much water does your pet drink per day? *
Your answer
Have there been any recent changes in the amount of water he/she drinks per day? If yes, please describe. *
Your answer
Does your pet ever dribble urine throughout the day or while sleeping? *
Your answer
Does your pet have trouble going the whole night without urinating or defecating? *
Your answer
Have you noticed any changes in the amount or frequency of your pet's bowel movements? If yes, please describe. *
Your answer
Have you noticed your pet limping, or acting stiff/painful in the morning or after getting up from rest? *
Your answer
If yes, does he/she improve after a while? How long does it seem to last? *
Your answer
Have you noticed any changes or problems with your pet's skin or hair/coat? If yes, please describe. *
Your answer
Have you noticed your pet having any coughing, sneezing, nasal discharge, eye discharge, scratching, or head shaking? *
Your answer
Have you noticed any unusual lumps or bumps on your pet? If yes, where and how long? *
Your answer
Does your pet have any past medical problems of which your veterinarian is not already aware? *
Your answer
Is your pet on any medications? If yes, please list. *
Your answer
Do you have any other concerns about your pet? *
Your answer
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