Senior Pet Checklist Owners Name* First Last Species* Canine Feline Pets Name* Weight gain? Yes No When did problem begin? Weight loss? Yes No When did problem begin? Appetite increase? Yes No When did problem begin? Appetite decrease? Yes No When did problem begin? Vomiting? Yes No When did problem begin? Diarrhea? Yes No When did problem begin? Colitis (stool with mucus or blood) ? Yes No When did problem begin? Constipation/difficult defecation? Yes No When did problem begin? Increased drinking? Yes No When did problem begin? Increased urine? Yes No When did problem begin? Coughing? Yes No When did problem begin? Weakness after exercise? Yes No When did problem begin? Panting? Yes No When did problem begin? Lumps/tumors? Yes No When did problem begin? Skin problems? Yes No When did problem begin? Describe? Yes No When did problem begin? Bad breath/sore gums/difficulty chewing? Yes No When did problem begin? Muscle tremors/shaking? Yes No When did problem begin? Weakness/incoordination? Yes No When did problem begin? Difficulty climbing stairs/increased stiffness? Yes No When did problem begin? Diminished vision? Yes No When did problem begin? Diminished hearing? Yes No When did problem begin? Housesoiling Urine horizontal surface Urine vertical surface Bowel movement Urinary incontinence Indoor elimination in view of family Goes outdoors, eliminates indoors on return Elimination in crate or sleeping area When did you first notice the problem(s)?Impaired learning/memory Decreased ability to work Forgets name/commands/previously learned tasks Decreased recognition of familiar people/animals When did you first notice the problem(s)?Social: Decreased interest in petting/affection Decreased tolerance of handling More possessive Increased need or demand for affection/attention Problems with social relationships with other pets When did you first notice the problem(s)?Disorientation Gets lost Confused Goes to wrong side of door Can’t find dropped food Can’t maneuver around obstacles When did you first notice the problem(s)?Anxiety/aggression Decreased tolerance of being left alone Increased irritability Restless/agitated Anxiety Can’t maneuver around obstacles Fearful Phobias Aggression When did you first notice the problem(s)?Purposeless/repetitive activity Vocal (whining, barking) Paces Circles Licks Stares into space Self-trauma Sucking Hallucinates When did you first notice the problem(s)?Sleep – wake cycles Wakes at night/restless sleep Decreased activity during the day/sleeps more When did you first notice the problem(s)?Apathy/depression Less reactive Listless Decreased interest in food Decreased self-grooming When did you first notice the problem(s)?Other problems/concerns (or use this space to describe any of the above in more detail)List medications, diet or supplements your pet is taking:Has your pet been previously diagnosed as having any medical problems? Y/N Describe:CAPTCHA Δ